Characteristics of double-chambered right ventricle in adult patients

BACKGROUND/AIMS

This study evaluated the clinical features of double-chambered right ventricle (DCRV) in adults. Most cases of DCRV are diagnosed and treated during childhood. Consequently, very few reports include cases in which its clinical characteristics are evident in adults.

METHODS

We reviewed the clinical data for 10 adult patients (age > or = 18 years) with DCRV.

RESULTS

Electrocardiogram showed right ventricular hypertrophy in 3 DCRV patients. All cases were associated with ventricular septal defect (VSD; 7 for perimembranous, 2 for muscular outlet, and 1 for the subarterial type). Surgical correction was done for 7 DCRV patients all of whom survived operations. Their follow-up echocardiogram showed the pressure gradient in their right ventricle was significantly decreased from 69.4 +/- 17.2 mmHg preoperatively to 10.2 +/- 5.0 mmHg postoperatively (p < 0.05). In the short-term follow-up, there was no significant increase in the pressure gradient in the right ventricle.

CONCLUSIONS

There are lots of cases of DCRV that are not diagnosed accurately in adults. In our experience, all DCRV cases had VSD and surgical correction of these cases showed excellent results. Therefore, accurate diagnosis of DCRV is necessary so that DCRV is not overlooked and operations are enabled within an appropriate time.

Right ventricular involvement in hypertrophic cardiomyopathy: a case report and literature review

Although hypertrophic cardiomyopathy (HCM) is classically considered a disease of the left ventricle, right ventricular (RV) abnormalities have also been reported. However, involvement of the right ventricle in HCM has not been extensively characterized. The literature regarding prevalence, genetics, patterns of involvement, histologic findings, symptoms, diagnosis, and treatment of RV abnormalities in HCM is reviewed. To highlight the salient points, a case is presented of apical HCM with significant RV involvement, with an RV outflow tract gradient and near obliteration of the RV cavity, in the absence of a left intraventricular gradient. Right ventricular involvement in HCM appears to be as heterogeneous as that of the left ventricle. The spectrum extends from mild concentric hypertrophy to more unusual severe, obstructive disease. While in some cases the extent of RV involvement correlates with left ventricular (LV) involvement, predominant RV disease can be seen as well. While the genetics of RV involvement have not been well characterized, histologic findings appear to be similar to those in the left ventricle, suggesting similar pathogenesis. Significant RV involvement may result in RV outflow obstruction and/or reduced RV diastolic filling, with potentially increased incidence of severe dyspnea, supraventricular arrhythmias, and pulmonary thromboembolism. The optimal treatment for patients with significant RV disease is unknown. Medical and surgical therapies have been attempted with variable success; experience with newer techniques such as percutaneous catheter ablation has not been reported. Further characterization of RV involvement in HCM is necessary to elucidate more clearly the clinical features and optimal treatments of this manifestation of HCM.

Gender-specific clinical characteristics of deep Q waves in hypertrophic cardiomyopathy

BACKGROUND

Despite male predominance in the prevalence of hypertrophic cardiomyopathy (HCM), repeated diagnosis at our institute indicates a possible higher prevalence of deep Q waves with HCM in women.

OBJECTIVE

The current study examined gender similarities and differences in the prevalence of deep Q waves in HCM and in the morphologic and electrocardiographic features of HCM with deep Q waves.

METHODS

Patients with HCM underwent cardiac magnetic resonance (CMR) imaging to identify the prevalence of deep Q waves in electrocardiographic limb leads, and to analyze the relationship between distribution patterns of deep Q waves and those of the localization of maximum amplitude of left ventricular (LV) hypertrophy. Contiguous LV short-axis images were obtained from the base toward the apex.

RESULTS

Of the 200 consecutive patients (172 males, aged 20-78 years; 28 females, aged 16-79 years) with HCM who underwent CMR imaging, 10 male and 8 female patients had deep Q waves. Deep Q waves were more prevalent in females with HCM than in their male counterparts (28.6% vs 5.8%, respectively; P<0.001). Of the 18 patients with deep Q waves, maximum wall thickness was localized at either the basal anterior wall or the midventricular septum in 9 (90%) of the 10 male patients and 6 (75%) of the 8 female patients. In both sexes, the Q wave distribution pattern of I and aVL and of II and aVF indicated localization of maximum hypertrophy at the midventricular septum in 6 (75%) of the 8 patients with the former pattern, and at the basal anterior wall in 9 (90%) of the 10 patients with the latter pattern.

CONCLUSIONS

Diagnostic deep Q waves were detected more frequently in female patients with HCM than in their male counterparts. In HCM with deep Q waves in limb leads, morphologic and electrocardiographic analysis showed similar features in both sexes.

Right Heart Dilatation in Adults: Congenital Causes

OBJECTIVE

The purpose of this article is to illustrate the common congenital cardiac lesions that are characterized by right-sided heart enlargement that may be seen on routine thoracic or cardiac imaging.

CONCLUSION

A systematic approach to the evaluation of the right heart and an understanding of the congenital abnormalities causing right chamber enlargement will allow the radiologist to diagnose unsuspected cardiac abnormalities on routine clinical thoracic and cardiac imaging as well as accurately identify these defects on dedicated cardiac CT or MRI examinations.

Imaging of the heart in pulmonary hypertension

Pulmonary hypertension (PH) is a disease of the pulmonary arteries resulting in a progressive increase in pulmonary vascular resistance, ultimately leading to right ventricular failure and death. It is a rare disease with a poor prognosis. The functional capacity of the right ventricle (RV) is a major prognostic determinant in PH. Our understanding of RV performance in PH has been hindered by the lack of techniques that give a reliable picture of right ventricular morphology and function. There have been recent major advances in our understanding of the mechanism of disease development, in the diagnostic process and in the treatment of PH. There are now three classes of medications that are effective in the treatment of PH: prostanoids, endothelin receptor antagonists and phosphodiesterase-5 inhibitors. Therapeutic advances in the management of PH have reinforced the requirement for non-invasive, accurate and reproducible methods of assessment to act as 'end-points' to measure the effects of treatment. It is our opinion that the most useful 'end-point' would be one that evaluates right heart morphology and function. We introduce and discuss the techniques currently used to image the heart in patients with PH. Imaging modalities discussed include echocardiography, radionuclide ventriculography, cardiac computed tomography and cardiac magnetic resonance (CMR) imaging focusing on the rapidly evolving technique of CMR imaging.

New approaches to the diagnosis of left and right ventricular hypertrophy by means of dipolar electrocardiotopography

OBJECTIVE

The aim of this work was to describe a new approach to noninvasive differential diagnosis of left and right ventricular hypertrophies (LVH and RVH) caused by the arterial or lung hypertensions.

METHODS

The vectorcardiographic measurements were analyzed by means of dipolar electrocardiotopography (DECARTO) technique based upon a simplified spherical model of the heart. The characteristics of LVH and RVH are obtained from the decartograms of activation duration. The integral indices of hypertrophy for the left ventricle and right ventricle (ILVH and IRVH) are formulated on the basis of the surface integrals of activation duration calculated over the regions where left and right ventricles are projected. The diagnostic decision is made through the comparison of ILVH and IRVH with specified threshold values. For comparison, the sums of wave amplitudes used in the orthogonal vectorcardiography, Rx+Sz for LVH and Rz+Sx for RVH, were also considered.

RESULTS

The study included 141 males and 191 females aged 45+/-15 years, with reliably verified state of the heart, in particular, 143 persons without hypertrophy, 129 persons with LVH, and 60 persons with RVH. The ROC curves for criteria under study were statistically analysed. As a result, the ILVH criterion is preferable to Rx+Sz with confidence level greater than 95%, and the IRVH criterion is preferable to Rz+Sx with confidence level close to 99%.

CONCLUSION

The proposed DECARTO method, initially intended mainly for intelligible-pictorial visualization of vectorcardiographic data, provides also some increase of diagnostic accuracy in recognition of the left and right ventricular hypertrophies as compared to the standard electrocardiography and orthogonal vectorcardiography.

Lungenerkrankungen und Herzfunktion

The most severe cardiac sequel to lung disease is the load on the right ventricle due to pulmonary hypertension with the development of a cor pulmonale. This is characterized by hypertrophy and/or dilatation of the right ventricle because of a primary impairment of lung function and/or lung structure. The most important pathomechanisms for the development of pulmonary hypertension are vessel obliteration, mechanical lesions, primary vascular or extra-vascular inflammation and hypoxic vasoconstriction. Chronic obstructive pulmonary disease (COPD) is one of the most important reasons for chronic cor pulmonale. A further very common reason is obstructive sleep apnea syndrome, especially if combined with a COPD. In this case, the prevalence of cor pulmonale can reach 80%. The development of a chronic cor pulmonale is the most striking negative prognostic factor for these patients. Only 30% of COPD patients with cor pulmonale survive longer than 5 years, and only early detection of the disturbances to respiration which might potentially lead to cor pulmonale and their subsequent therapy are able to improve the patient's prognosis. Furthermore, pulmonary diseases may also have an impact on the left heart side in terms of an impairment of left heart function or by inducing severe arrhythmias . Thus, lung diseases may have both a significant impact on right and left heart performance.

NT-proBNP can be used to detect right ventricular systolic dysfunction in pulmonary hypertension

Right ventricular systolic dysfunction (RVSD) at baseline (pre-treatment) predicts early death in patients with pulmonary hypertension (PH). However, RVSD can only be detected reliably by prohibitively invasive or expensive techniques. N-terminal B-type natriuretic peptide concentration ([NT-proBNP]) correlates with RV function in PH; however, an [NT-proBNP] threshold that indicates RVSD in individual patients has not previously been determined. Twenty-five patients with PH (pulmonary arterial hypertension (n = 19) or chronic thromboembolic PH (n = 6)) underwent cardiovascular magnetic resonance (CMR) imaging and NT-proBNP measurement at baseline. [NT-proBNP] was correlated against RV dimensions and ejection fraction (RVEF) measured directly by CMR imaging. The ability of NT-proBNP to detect RVSD (defined as a CMR-derived RVEF >2 SDS below control values) was tested and predictors of [NT-proBNP] identified. [NT-proBNP] correlated negatively with RVEF. RVSD was present in nine out of 25 patients. An [NT-proBNP] threshold of 1,685 pg.mL(-1) was sensitive (100%) and specific (94%) in detecting RVSD. RVEF and RV mass index independently predicted [NT-proBNP]. In pulmonary hypertension, a baseline N-terminal B-type natriuretic peptide concentration of >1,685 ng.L(-1) suggests right ventricular systolic dysfunction, and thus an increased risk of early death. N-terminal B-type natriuretic peptide could prove useful as an objective, noninvasive means of identifying patients with pulmonary hypertension who have right ventricular systolic dysfunction at presentation.

[Unusual cause of right heart failure decompensation in 21-years old patient with idiopathic pulmonary arterial hypertension -- a case report]

The authors describe a case of 21-years old woman with idiopathic pulmonary arterial hypertension with atypical clinical consequences of massive internal bleeding. Despite significant hypovolemia clinical and laboratory presentation was one of RV failure with dilatation of right heart ventricle and increased plasma level of markers of myocardial stretch and injury (NT-proBNP and troponin, respectively). This is attributed to impaired right ventricular coronary perfusion and hypoxia. Intensive treatment restored baseline RV conditions and at 15 months follow-up no persistent right heart impairment was observed. This case demonstrates that bleeding should be also considered in differential diagnosis of exacerbation of right ventricular failure in patients with pulmonary arterial hypertension.

A Quadricuspid Aortic Valve with Atrial Septal Defect

A quadricuspid aortic valve (QAV) is a rare congenital heart defect, previously described as an incidental finding at the time of surgery or postmortem, which is now being increasingly detected by 2D transthoracic or transesophageal echocardiogram. With advances in echocardiography, secondary cardiac anomalies are also being described in association with QAV. Herein we describe a patient with QAV with a secundum atrial septal defect.

Electrocardiography in the diagnosis of right ventricular hypertrophy in children

OBJECTIVE

Although the electrocardiogram is commonly obtained in the evaluation of patients with pulmonary hypertension, its value as a screening test for right ventricular hypertrophy or pulmonary hypertension is unclear. Therefore, we sought to determine the value of an electrocardiogram in the diagnosis of right ventricular hypertrophy using echocardiography as the gold standard.

METHODS

We identified children without congenital heart disease who underwent evaluation for suspected pulmonary hypertension that included both an electrocardiogram and echocardiography within a specified time frame.

RESULTS

A total of 76 echocardiography-electrocardiogram pairs for pulmonary hypertension were identified. Although there was a significant relationship between electrocardiogram and echocardiography evidence of right ventricular hypertrophy, the sensitivity of an electrocardiogram in diagnosing echocardiography-documented right ventricular hypertrophy was only 69%, and the positive predictive value was 67%. There was no relationship between electrocardiogram changes and Doppler tricuspid regurgitation gradient.

CONCLUSION

Despite a statistically significant relationship between an electrocardiogram and echocardiography in the diagnosis of right ventricular hypertrophy, an electrocardiogram has limited value as a screening tool for right ventricular hypertrophy because of its relatively low sensitivity and positive predictive value.

Intracardiac thrombus and pulmonary embolism with cavitation and pneumomediastinum in a patient with protein S deficiency

We present a case of intracardiac thrombus with pulmonary embolism and pulmonary infarction in a patient with protein S deficiency. Secondary infection of the pulmonary infarction resulted in pneumomediastinum. Thrombus in an unusual location in a young patient without known predisposing conditions is a characteristic feature of a hereditary thrombophilic disorder. Cavitation within a lesion adjacent to the mediastinal pleura can result in pneumomediastinum.

Interpretation of electrocardiographic abnormalities in hypertrophic cardiomyopathy with cardiac magnetic resonance

AIMS

To clarify the mechanisms of electrocardiographic abnormalities in hypertrophic cardiomyopathy, 102 patients were examined with cardiac magnetic resonance. Distribution and magnitude of hypertrophy and late-enhancement were correlated with electrocardiographic abnormalities.

METHODS AND RESULTS

Abnormal Q waves were associated with greater upper anterior septal thickness (22+/-7 mm vs. 18+/-5 mm, P=0.001) and increased ratios of upper anterior septum to mean inferolateral (P=0.01), anterolateral (P=0.002), apical (P=0.001), and right ventricular (P=0.001) wall thickness. There was no relation between abnormal Q waves and late-enhancement, except for Q waves >/=40 ms (P=0.02). Conduction disturbances and absent septal Q waves were associated with late-enhancement (89 vs. 45%, P=0.01 and 75 vs. 39%, P=0.002, respectively). The depth of negative T waves was related to an increased ratio of the mean thickness between apical and basal level (P=0.01), and to the presence of apical late-enhancement (P=0.03).

CONCLUSION

Abnormal Q waves reflect the interrelation between upper anterior septal thickness and other regions of the left and right ventricles, and wider Q waves are associated with late-enhancement. Conduction disturbances and absent septal Q waves are associated with late-enhancement. The depth of negative T waves is related to craniocaudal asymmetry and apical late-enhancement.

[Double chamber right ventricle. About 3 cases]

The double chambered right ventricle is a rare congenital abnormality. It creates an obstacle for the right ventricular ejection. The cardiac ultra sonography examination allows the diagnosis in most majority of cases. The angiography is performed in difficult cases. We report 3 cases of infundibular stenosis with normal interventricular septum. The diagnosis was suspected for the 3 cases by the constellation of clinical findings pointing to systolic murmur over the precordium, and the electrocardiography showing right ventricular hypertrophy. It is confirmed by the echocardiogram and the hemodynamic exploration with a trans stenotic gradient evaluated at 72,80 and 80mmHg. The 3 patients underwent surgery and had all good post operative follow up. These 3 observations allow us to recall the epidemiological, embryological, clinical and echocardiographic particularities of pure infundibular stenosis and to determin the adequate treatment and the prognosis.

Usefulness of magnetic resonance imaging for the diagnosis of right ventricular dysplasia in children

Cardiac magnetic resonance (CMR) has been helpful in adults in the diagnosis of arrhythmogenic right ventricular dysplasia. Short of direct surgical observation or autopsy, no gold standard exists. CMR diagnostic criteria include right atrial and ventricular dilation, regional right ventricular (RV) wall motion abnormalities, outflow tract ectasia, and myocardial fatty infiltration. To determine whether adult diagnostic criteria are useful in children referred for CMR for this diagnosis, the images and records of 81 patients (aged 11.5 +/- 5.5 years) over an 8-year period were reviewed. Histories included ventricular tachycardia, palpitations, dilated right ventricle, syncope, near sudden death, or family history of RV dysplasia. Four families were studied with parents who had RV dysplasia diagnosed by surgery, explanted heart, or CMR. CMR imaging included T1-weighted imaging, cine, 1-dimensional RV myocardial tagging, and phase-encoded velocity mapping, and 2 patients underwent delayed-enhancement CMR. Only 1 of the 81 patients met 5 of the criteria. None of the others met >2 of the criteria, and only 2 patients met 1 or 2 criteria. For questionable regional wall motion abnormalities, RV myocardial tagging was helpful. In conclusion, CMR of patients with a history suspicious for the diagnosis of RV dysplasia is a low-yield test in children. This may be due to the evolving nature of the disease, which does not manifest itself from a morphologic or ventricular-function standpoint until later in development. Follow-up studies as patients age may be advantageous.