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RV function Prognostic implications in heart failure

RV function Prognostic implications in heart failure. Efthimios Anagnostou M.D. No disclosures . The prognostic value of RV function in cardiovascular disease. . After AMI Congestive HF Valvular HD Congenital HD After HT Pulmonary Embolism Pulmonary HTN HFpEF.

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RV function Prognostic implications in heart failure

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  1. RV function Prognostic implications in heart failure Efthimios Anagnostou M.D.

  2. No disclosures

  3. The prognostic value of RV function in cardiovascular disease. • After AMI • Congestive HF • Valvular HD • Congenital HD • After HT • Pulmonary Embolism • Pulmonary HTN • HFpEF

  4. reduced RVEF is an independent prognostic factor in moderate to severe CHF. Courtesy C.Celton-Saty

  5. RVEF predicts prognosis in CHF

  6. Larose RVEF: Prognostic impact late after AMI • Pts, late after MI , RVEF<40% • CMRRVEF and survival @ 17 months RVEF≥40% RVEF<40% Larose JACC 2007

  7. Better survival & Better exercise capacity

  8. RV function + PH predict survival in CHF 379 CHF pts, LVEF<35% ,DCM & IHD, optimized Rx RHC with thermodilution RVEF Normal PAP +Normal RVEF High PAP +Low RVEF Ghio, JACC 2001

  9. RV dilatation predicts survival in CHF 380 CHF pts, LVEF<45% VS controls DILATED RV IN 25% of pts RVESVi: independent predictor of mortality Bourantas EJHF 2011

  10. Despite… • variations in study populations, • severity and substrates of disease, • methodologies of assessment. RV dysfunction portends an inferior survival.

  11. Shah PK, Maddahi J, Staniloff HM, et al. Variable spectrum and prognostic implications of left and right ventricular ejection fractions in patients with and without clinical heart failure after acute myocardial infarction. Am J Cardiol1986;58:387–93. [ 2. Niebauer J, Clark AL, Anker SD, et al. Three year mortality in heart failure patients with very low left ventricular ejection fractions. Int J Cardiol1999;70:245–7.  3. Polak JF, Holman BL, Wynne J, et al. 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;2:217–24. 4. Gavazzi A, Berzuini C, Campana C,  Am J Cardiol1986;58:387–93. [ et al. Value of right ventricular ejection fraction in predicting short-term prognosis of patients with severe chronic heart failure. J.Heart Lung Transplant 1997;16:774–85.  5. Juilliere Y, Barbier G, Feldmann L, et al. Additional predictive value of both left and right ventricular ejection fractions on long-term survival in idiopathic dilated cardiomyopathy. Eur Heart J 1997;18:276–80.  6. Di Salvo TG, Mathier M, Semigran MJ, et al. Preserved right ventricular ejection fraction predicts exercise capacity and survival in advanced heart failure. J Am Coll Cardiol 1995;25:1143–53.  7. Mehta SR, Eikelboom JW, Natarajan MK, et al. Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J Am Coll Cardiol 2001;37:37–43. 8. Bowers TR, O'Neill WW, Grines C, et al. Effect of reperfusion on biventricular function and survival after right ventricular infarction. N Engl J Med 1998;338:933–40.  9. La Vecchia L, Zanolla L, Varotto L, et al. Reduced right ventricular ejection fraction as a marker for idiopathic dilated cardiomyopathy compared with ischemic left ventricular dysfunction. Am Heart J 2001;142:181–9.  10. Nakamura S, Iwasaka T, Kimura Y, et al. Right ventricular ejection fraction during exercise in patients with recent myocardial infarction: effect of the interventricular septum. Am Heart J 1994;127:49–55.  11. Korr KS, Gandsman EJ, Winkler ML, et al. Hemodynamic correlates of right ventricular ejection fraction measured with gated radionuclide angiography. Am J Cardiol 1982;49:71–7.  12. Marmor A, Geltman EM, Biello DR, et al. Functional response of the right ventricle to myocardial infarction: dependence of the site of left ventricular infarction. Circulation 1981;64:1005–11.  13. Atherton JJ, Moore TD, Lele SS, et al. Diastolic ventricular interaction in chronic heart failure. Lancet 1997;349:1720–4.  14. Janicki JS, Weber KT. The pericardium and ventricular interaction, distensibility, and function. Am J Physiol 1980;238:H494–503.  15. Baker BJ, Wilen MM, Boyd CM, et al. Relation of right ventricular ejection fraction to exercise capacity in chronic left ventricular failure. Am J Cardiol1984; 54:596–9.  16. Atherton JJ, Moore TD, Thomson HL, et al. Restrictive left ventricular filling patterns are predictive of diastolic ventricular interaction in chronic heart failure. J Am Coll Cardiol 1998;31:413–8.  17. Giannuzzi P, Imparato A, Temporelli PL, et al. Doppler-derived mitral deceleration time of early filling as a strong predictor of pulmonary capillary wedge pressure in postinfarction patients with left ventricular systolic dysfunction. J Am Coll Cardiol 1994;23:1630–7.  18. Atherton JJ, Thomson HL, Moore TD, et al. Diastolic ventricular interaction: a possible mechanism for abnormal vascular responses during volume unloading in heart failure. Circulation 1997;96:4273–9.  19. Atherton JJ, Blackman DJ, Moore TD, et al. Diastolic ventricular interaction in chronic heart failure: relation to heart rate variability and neurohumoral status. Heart Vessels 1998;13:269–77.  20. Francis GS, Cohn JN, Johnson G, et al. Plasma norepinephrine, plasma renin activity, and congestive heart failure. Relations to survival and the effects of therapy in V-HeFT II. The V-HeFT VA cooperative studies group.Circulation 1993;87:VI40–I48.  21. Osterziel KJ, Hanlein D, Willenbrock R, et al. Baroreflex sensitivity and cardiovascular mortality in patients with mild to moderate heart failure. Br Heart J 1995;73:517–22.  22. Ionescu AA, Ionescu AA, Payne N, et al. Subclinical right ventricular dysfunction in cystic fibrosis. A study using Doppler echocardiography. Am J Respir Crit Care Med 2001;163:1212–8 23. Kukulski T, Hubbert L, Arnold M, et al. Normal regional right ventricular function and its change with age: a Doppler myocardial imaging study. J Am Soc Echocardiogr 2000;13:194–204.  RV dysfunction Bibliography 30 years ago … Insidiously ignored until the BEST trial…

  12. distribution of RVEF in CHF 2008 pts, from the BEST study, LVEF<35%,NYHA III/IV RadionuclideRVEF and mortality @ 24 months Mortality 47% Mortality 27% =63% =37% Meyer et al, Circulation 2012

  13. What is RV failure ? an Increased Preload (RA pressure) is required to maintain adequate CO Inability of the RV to maintain cardiac output through the pulmonary vascular bed at normal central venous pressures.

  14. The commonest cause of RV Dysfunction is Left Heart Disease • LV Systolic Dysfunction • CAD • Valve Disease • LV Diastolic Dysfunction Hypertension • Restrictive Cardiomyopathy • HCM HFrEF HFpEF

  15. CHF causes Pulmonary Hypertension leading to Right Ventricular Failure Group 2 PH mPA>25mmHg PCWP >15mmHg CO normal or low MV disease PAP HTN PCWP LA pressure AoV disease HFpEF HFrEF

  16. Mechanism of PH in CHF 1000 CHF pts undergoing transplant evaluation Drazner J Heart Lung Transplant 1999 Correlation nice and straight and fairly tight indicating therefore that PAP is driven passively by PCWP

  17. Mechanism of PH in CHF intimal Fibrosis PCWP PAP This may or may not result in rise in the PAP with a consequent rise in the TPG or PVR

  18. Different Hemodynamic Stages in GROUP 2 PH

  19. Mechanism of PH in CHF 1000 CHF pts undergoing transplant evaluation Out of proportion PH Drazner J Heart Lung Transplant 1999 because of vascular changes in the arterial side of pulmonary circulation

  20. CHF, PH- CHF, PH+ 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 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

  21. Mechanism of PH in CHF PCWP PAP As a consequence of rise in PAP, PVR and PVH, the RV runs into trouble

  22. PH and impaired Exercise capacity in CHF 320 pts Di Salvo JACC 1995 a consequence of rise in PVR is the dramatic decrease in CO both at rest and during exercise

  23. ADULT HEART TRANSPLANTATION Kaplan Meyer estimates of mortality 1999-2007 stratified by PVR < 2 WU 2- 4 WU > 4 WU

  24. Ventricular Interdependence

  25. RV stroke volume predicts prognosis in PAH 64 pts, CMR, RHC, 6MWT Wolferen, EHJ 2007

  26. RV failure RVH RV dilatation RA dilatation D-shaped LV Tricuspid Regurgitation

  27. The shrinking LV… This is the beginning This is the end, my friend

  28. HFpEF

  29. PASP estimates are a risk factor for death.

  30. Markers of RV Dysfunction associated with clinical status and prognosis • Systolic Performance • RVEF • RVFAC • TAPSE • RV MPI • Hemodynamics • RA pressure • CI • Maximal dP/dT • Pressure–volume Measurements • Ventricular elastance • Preload recruitable stroke work • Diastolic Filling • Tissue Doppler indices • Isovolumic acceleration • Syst/Diast myocardial velocities • Right-sided Dilation • RV dilation absolute/ relative to LV • RA size • TR Which?

  31. We would be poorly served by buying into the concept that an RVEF is the only ‘‘reference standard,’’ without recognition of its shortcomings.

  32. 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. Multimodality Comparison of Quantitative Volumetric Analysis of the Right Ventricle Sugeng, J A C C i m g 2 0 1 0

  33. When grappling with what measure should be adopted to evaluate RV systolic function, we are left with the classic answer: it depends!

  34. Conclusions • 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

  35. Thank you

  36. 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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