1
|
Ladányi Z, Eltayeb A, Fábián A, Ujvári A, Tolvaj M, Tokodi M, Choudhary KA, Kovács A, Merkely B, Vriz O, Lakatos BK. The effects of mitral stenosis on right ventricular mechanics assessed by three-dimensional echocardiography. Sci Rep 2024; 14:17112. [PMID: 39048660 PMCID: PMC11269591 DOI: 10.1038/s41598-024-68126-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 07/19/2024] [Indexed: 07/27/2024] Open
Abstract
Mitral stenosis (MS) is a complex valvular pathology with significant clinical burden even today. Its effect on the right heart is often overlooked, despite it playing a considerable part in the symptomatic status. We enrolled 39 mitral valve stenosis patients and 39 age- and gender-matched healthy controls. They underwent conventional, speckle-tracking and 3D echocardiographic examinations. The 3D data was analyzed using the ReVISION software to calculate RV functional parameters. In the MS group, 3D RV ejection fraction (EF) (49 ± 7% vs. 61 ± 4%; p < 0.001), global circumferential (GCS) (- 21.08 ± 5.64% vs. - 25.07 ± 4.72%; p = 0.001) and longitudinal strain (GLS) (- 16.60% ± 4.07% vs. - 23.32 ± 2.82%; p < 0.001) were reduced. When comparing RV contraction patterns between controls, MS patients in sinus rhythm and those with atrial fibrillation, radial (REF) (32.06 ± 5.33% vs. 23.62 ± 7.95% vs. 20.89 ± 6.92%; p < 0.001) and longitudinal ejection fraction (LEF) (24.85 ± 4.06%; 17.82 ± 6.16% vs. 15.91 ± 4.09%; p < 0.001) were decreased in both MS groups compared to controls; however, they were comparable between the two MS subgroups. Anteroposterior ejection fraction (AEF) (29.16 ± 4.60% vs. 30.87 ± 7.71% vs. 21.48 ± 6.15%; p < 0.001) showed no difference between controls and MS patients in sinus rhythm, while it was lower in the MS group with atrial fibrillation. Therefore, utilizing 3D echocardiography, we found distinct morphological and functional alterations of the RV in MS patients.
Collapse
Affiliation(s)
- Zsuzsanna Ladányi
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, Budapest, 1122, Hungary.
| | - Abdalla Eltayeb
- King Faisal Specialist Hospital and Research Center Hospital, Riyadh, Saudi Arabia
| | - Alexandra Fábián
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, Budapest, 1122, Hungary
| | - Adrienn Ujvári
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, Budapest, 1122, Hungary
| | - Máté Tolvaj
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, Budapest, 1122, Hungary
| | - Márton Tokodi
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, Budapest, 1122, Hungary
- Department of Surgical Research and Techniques, Semmelweis University, Budapest, Hungary
| | | | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, Budapest, 1122, Hungary
- Department of Surgical Research and Techniques, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, Budapest, 1122, Hungary
| | - Olga Vriz
- King Faisal Specialist Hospital and Research Center Hospital, Riyadh, Saudi Arabia
- Ospedale Sant'Antonio, San Daniele del Friuli, Italy
| | - Bálint Károly Lakatos
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, Budapest, 1122, Hungary
| |
Collapse
|
2
|
Brener MI, Kanwar MK, Lander MM, Hamid NB, Raina A, Sethi SS, Finn MT, Fried JA, Raikhelkar J, Masoumi A, Rosenblum HR, Maurer MS, Sayer G, Burkhoff D, Uriel N. Impact of Interventricular Interaction on Ventricular Function: Insights From Right Ventricular Pressure-Volume Analysis. JACC. HEART FAILURE 2024; 12:1179-1192. [PMID: 38206234 DOI: 10.1016/j.jchf.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/31/2023] [Accepted: 12/01/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Interventricular interactions may be responsible for the decline in ventricular performance observed in various disease states that primarily affect the contralateral ventricle. OBJECTIVES This study sought to quantify the impact of such interactions on right ventricular (RV) size and function using clinically stable individuals with left ventricular assist devices (LVADs) as a model for assessing RV hemodynamics while LV loading conditions were acutely manipulated by changing device speed during hemodynamic optimization studies (ie, ramp tests). METHODS The investigators recorded RV pressure-volume loops with a conductance catheter at various speeds during ramp tests in 20 clinically stable HeartMate3 recipients. RESULTS With faster LVAD speeds and greater LV unloading, indexed RV end-diastolic volume increased (72.28 ± 15.07 mL at low speed vs 75.95 ± 16.90 at high speed; P = 0.04) whereas indexed end-systolic volumes remained neutral. This resulted in larger RV stroke volumes and shallower end-diastolic pressure-volume relationships. Concurrently, RV end-systolic pressure decreased (31.58 ± 9.75 mL at low speed vs 29.58 ± 9.41 mL at high speed; P = 0.02), but contractility, as measured by end-systolic elastance, did not change significantly. The reduction in RV end-systolic pressure was associated with a reduction in effective arterial elastance from 0.65 ± 0.43 mm Hg/mL at low speed to 0.54 ± 0.33 mm Hg/mL at high speed (P = 0.02). CONCLUSIONS Interventricular interactions resulted in improved RV compliance, diminished afterload, and did not reduce RV contractility. These data challenge the prevailing view that interventricular interactions compromise RV function, which has important implications for the understanding of RV-LV interactions in various disease states, including post-LVAD RV dysfunction.
Collapse
Affiliation(s)
- Michael I Brener
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Manreet K Kanwar
- Cardiovascular Institute at Alleghany Health Network, Pittsburgh, Pennsylvania, USA
| | - Matthew M Lander
- Cardiovascular Institute at Alleghany Health Network, Pittsburgh, Pennsylvania, USA
| | - Nadira B Hamid
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | - Amresh Raina
- Cardiovascular Institute at Alleghany Health Network, Pittsburgh, Pennsylvania, USA
| | - Sanjum S Sethi
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Matthew T Finn
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Justin A Fried
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Jayant Raikhelkar
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Amirali Masoumi
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Hannah R Rosenblum
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Mathew S Maurer
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Gabriel Sayer
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA.
| |
Collapse
|
3
|
Gelzinis TA. Pulmonary Hypertension in 2021: Part I-Definition, Classification, Pathophysiology, and Presentation. J Cardiothorac Vasc Anesth 2021; 36:1552-1564. [PMID: 34344595 DOI: 10.1053/j.jvca.2021.06.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/26/2021] [Accepted: 06/30/2021] [Indexed: 11/11/2022]
Abstract
The World Symposium on Pulmonary Hypertension (WSPH) was organized by the World Health Organization in 1973 in response to an increase in pulmonary arterial hypertension in Europe caused by aminorex, an appetite suppressant. The mandate of this meeting was to review the latest clinical and scientific research and to formulate recommendations to improve the diagnosis and management of pulmonary hypertension (PH).1 Since 1998, the WSPH has met every five years and in 2018, the sixth annual WSPH revised the hemodynamic definition of PH. This two-part series will review the updated definition, classification, pathophysiology, presentation, diagnosis, management, and perioperative management of patients with PH. In the first part of this series, the definition, classification, pathophysiology, and presentation will be reviewed.
Collapse
|
4
|
Sanders JL, Koestenberger M, Rosenkranz S, Maron BA. Right ventricular dysfunction and long-term risk of death. Cardiovasc Diagn Ther 2020; 10:1646-1658. [PMID: 33224778 DOI: 10.21037/cdt-20-450] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sudden cardiac death (SCD), or sudden loss of life-sustaining systemic and cerebral perfusion, is most often due to left ventricular (LV) dysfunction secondary to ischemic or structural cardiac disease or channelopathies. Degeneration of sinus rhythm into ventricular tachycardia and ultimately ventricular fibrillation is the final common pathway for most heart failure patients. Right ventricular (RV) dysfunction is recognized as an independent contributor to worsening heart failure. There is emerging evidence that RV dysfunction may also be an independent predictor of SCD. This review examines the role of RV dysfunction on modifying long term risk of SCD, and explores possible mechanisms that may underlie SCD. The RV has unique anatomy and physiology compared to the LV. Subsequently, we begin with a review of cardiac embryology, focusing on the chambers, valves, coronary arteries, and cardiac conduction system to understand the origins of RV dysfunction. Static and dynamic physiology of the RV is contrasted with that of the LV. Particular emphasis is placed on ventriculo-arterial coupling, mechanical cardiac constraint, and ventricular interdependence. The epidemiology of SCD is briefly reviewed to highlight how causes of SCD are age-specific. In turn, the age-specific causes of RV dysfunction are presented, including those which predominate in childhood and adolescence [arrhythmogenic RV dysplasia (ARVD) and hypertrophic cardiomyopathy (HCM)] and older adulthood (cardiac ischemia, chronic congestive heart failure and post-capillary pulmonary hypertension, and pulmonary hypertension). There is a clear need for additional studies on the independent contribution of RV dysfunction to overall functional capacity, SCD-associated mortality, and non-SCD-associated mortality. Discovery would be aided by the development of prospective cohorts with excellent RV phenotyping, coupled with deeper biologic measurements linking mechanisms to clinically relevant outcomes.
Collapse
Affiliation(s)
- Jason L Sanders
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Martin Koestenberger
- Divison of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Cologne Cardiovascular Research Center, Heart Center at the University of Cologne, Cologne, Germany
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
5
|
Lakatos BK, Nabeshima Y, Tokodi M, Nagata Y, Tősér Z, Otani K, Kitano T, Fábián A, Ujvári A, Boros AM, Merkely B, Kovács A, Takeuchi M. Importance of Nonlongitudinal Motion Components in Right Ventricular Function: Three-Dimensional Echocardiographic Study in Healthy Volunteers. J Am Soc Echocardiogr 2020; 33:995-1005.e1. [PMID: 32620323 DOI: 10.1016/j.echo.2020.04.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Global right ventricular (RV) function is determined by the interplay of different motion components related to the myofiber architecture, and the relative importance of these components is still not thoroughly characterized. The aims of this study were to quantify the relative contributions of longitudinal, radial, and anteroposterior motion components to global RV function and to examine their determining factors in a large cohort of healthy volunteers using three-dimensional echocardiography. METHODS Three hundred healthy adults with a balanced age range and an equal sex distribution were investigated at two centers. A three-dimensional mesh model of the right ventricle was generated, and its motion was decomposed along the three anatomically relevant axes. Multiplicative relative contributions were measured by dividing the ejection fraction (EF) values generated by shortening in the longitudinal, radial, and anteroposterior directions by global RV EF (longitudinal EF index [LEFi], radial EF index [REFi], and anteroposterior EF index, respectively). The circumferential contribution was defined as shortening in the radial and anteroposterior directions, omitting only longitudinal shortening. RESULTS Circumferential EF index was markedly higher compared with LEFi (79 ± 7% vs 47 ± 9%, P < .001). LEFi (47 ± 9%) and anteroposterior EF index (49 ± 7%) were found to be similar in the pooled population, whereas REFi (44 ± 10%) was lower (P < .001). In younger individuals (20-39 years of age), the relative contribution of longitudinal shortening was significantly higher compared with the radial component; however, in the older age groups, LEFi and REFi were comparable. Age, body surface area, heart rate, and RV end-diastolic volume were independent predictors of LEFi and REFi, but all with opposite effects on the two motion directions. CONCLUSIONS In contrast to the traditional viewpoint, the contributions of the radial and anteroposterior motion directions may be of comparable significance with that of longitudinal shortening in determining global RV function. Standard parameters referring only to longitudinal shortening of the right ventricle may be inadequate to characterize RV function thoroughly.
Collapse
Affiliation(s)
| | - Yosuke Nabeshima
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Márton Tokodi
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Yasufumi Nagata
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | | | - Kyoko Otani
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Tetsuji Kitano
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Alexandra Fábián
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Adrienn Ujvári
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | | | - Béla Merkely
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Attila Kovács
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary.
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| |
Collapse
|
6
|
|
7
|
Tavazzi G, Bergsland N, Alcada J, Price S. Early signs of right ventricular systolic and diastolic dysfunction in acute severe respiratory failure: the importance of diastolic restrictive pattern. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:649-656. [PMID: 31762290 PMCID: PMC7206565 DOI: 10.1177/2048872619883399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The incidence and pathophysiology of right ventricular failure in patients with severe respiratory insufficiency has been largely investigated. However, there is a lack of early signs suggesting right ventricular systolic and diastolic dysfunction prior to acute cor pulmonale development. METHODS We conducted a retrospective analytical cohort study of patients for acute respiratory distress syndrome undertaking an echocardiography during admission in the cardiothoracic intensive care unit. Patients were divided according to treatment: conventional protective ventilation (38 patients, 38%); interventional lung assist (23 patients, 23%); veno-venous extracorporeal membrane oxygenation (37 patients, 37%). Systolic and diastolic function was studied assessing, respectively: right ventricular systolic longitudinal function (tricuspid annular plane systolic excursion) and systolic contraction duration (tricuspid annular plane systolic excursion length); right ventricular diastolic filling time and right ventricular diastolic restrictive pattern (presence of pulmonary valve presystolic ejection wave). Correlation between the respiratory mechanics and systo-diastolic parameters were analysed. RESULTS In 98 patients studied, systolic dysfunction (tricuspid annular plane systolic excursion <16 mm) was present in 33.6% while diastolic restrictive pattern was present in 64%. A negative correlation was found between tricuspid annular plane systolic excursion and tricuspid annular plane systolic excursion length (P<0.0001; r -0.42). Tricuspid annular plane systolic excursion and tricuspid annular plane systolic excursion length correlated with right ventricular diastolic filling time (P<0.001; r -0.39). Pulmonary valve presystolic ejection wave was associated with tricuspid annular plane systolic excursion (P<0.0001), tricuspid annular plane systolic excursion length (P<0.0001), right ventricular diastolic filling time (P<0.0001), positive end-expiratory pressure (P<0.0001) and peak inspiratory pressure (P<0.0001). CONCLUSION Diastolic restrictive pattern is present in a remarkable percentage of patients with respiratory distress syndrome. Bedside echocardiography allows a mechanistic evaluation of systolic and diastolic interaction of the right ventricle.
Collapse
Affiliation(s)
- Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Italy.,Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy
| | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, State University of New York, USA
| | - Joana Alcada
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK.,Inflammation, Repair and Development, Imperial College London, UK
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| |
Collapse
|
8
|
Early Right Ventricular Systolic Dysfunction and Pulmonary Hypertension Are Associated With Worse Outcomes in Pediatric Acute Respiratory Distress Syndrome. Crit Care Med 2019; 46:e1055-e1062. [PMID: 30095502 DOI: 10.1097/ccm.0000000000003358] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The prevalence and importance of early right ventricular dysfunction and pulmonary hypertension in pediatric acute respiratory distress syndrome are unknown. We aimed to describe the prevalence of right ventricular dysfunction and pulmonary hypertension within 24 hours of pediatric acute respiratory distress syndrome diagnosis and their associations with outcomes. DESIGN Retrospective, single-center cohort study. SETTING Tertiary care, university-affiliated PICU. PATIENTS Children who had echocardiograms performed within 24 hours of pediatric acute respiratory distress syndrome diagnosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Between July 1, 2012, and June 30, 2016, 103 children met inclusion criteria. Echocardiograms were analyzed using established indices of right ventricular and left ventricular systolic function and for evidence of pulmonary hypertension. Echocardiographic abnormalities were common: 26% had low right ventricular fractional area change, 65% had low tricuspid annular plane systolic excursion, 30% had low left ventricular fractional shortening, and 21% had evidence of pulmonary hypertension. Abnormal right ventricular global longitudinal strain and abnormal right ventricular free wall strain were present in 35% and 40% of patients, respectively. No echocardiographic variables differed between or across pediatric acute respiratory distress syndrome severity. In multivariable analyses, right ventricular global longitudinal strain was independently associated with PICU mortality (odds ratio, 3.57 [1.33-9.60]; p = 0.01), whereas right ventricular global longitudinal strain, right ventricular free wall strain, and the presence of pulmonary hypertension were independently associated with lower probability of extubation (subdistribution hazard ratio, 0.46 [0.26-0.83], p = 0.01; subdistribution hazard ratio, 0.58 [0.35-0.98], p = 0.04; and subdistribution hazard ratio, 0.49 [0.26-0.92], p = 0.03, respectively). CONCLUSIONS Early ventricular dysfunction and pulmonary hypertension were detectable, prevalent, and independent of lung injury severity in children with pediatric acute respiratory distress syndrome. Right ventricular dysfunction was associated with PICU mortality, whereas right ventricular dysfunction and pulmonary hypertension were associated with lower probability of extubation.
Collapse
|
9
|
Singh I, Rahaghi FN, Naeije R, Oliveira RKF, Systrom DM, Waxman AB. Right Ventricular-Arterial Uncoupling During Exercise in Heart Failure With Preserved Ejection Fraction: Role of Pulmonary Vascular Dysfunction. Chest 2019; 156:933-943. [PMID: 31103695 DOI: 10.1016/j.chest.2019.04.109] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 04/08/2019] [Accepted: 04/29/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction is associated with shortened life expectancy in heart failure with preserved ejection fraction (HFpEF). The contribution of pulmonary vascular dysfunction to RV dysfunction in HFpEF is not well understood. METHODS We investigated rest and exercise invasive pulmonary hemodynamics, ventilation, and gas exchange in 67 patients with HFpEF (of whom 28 had an abnormal pulmonary vascular response during exercise referred to as HFpEF+PVR group and 39 had a normal pulmonary vascular response during exercise referred to as HFpEF group) and in 21 matched control subjects. RESULTS Both groups of patients with HFpEF had a markedly decreased peak oxygen consumption (Vo2), decreased oxygen delivery, and impaired chronotropic response. Single beat analysis of RV pressure waveforms was used to compute the end-systolic elastance (Ees) and pulmonary arterial elastance (Ea). Right ventricular-pulmonary artery (RV-PA) coupling was measured as the ratio of Ees/Ea. Exercise was associated with a preserved Ees response but a decreased Ees/Ea in patients with HFpEF with a normal PVR response, indicating partially preserved RV contractile reserve. In HFpEF+PVR, exercise-induced increase in Ees was markedly reduced, resulting in decreased Ees/Ea and RV-PA uncoupling. Patients with HFpEF+PVR with an exercise-induced decrease in Ees/Ea had lower pulmonary artery compliance, lower peak Vo2, and lower stroke volume than patients with HFpEF. CONCLUSIONS We conclude that RV-PA uncoupling is common in HFpEF and is caused by both intrinsic RV contractile impairment and afterload mismatch. Resting and dynamic RV-PA uncoupling in HFpEF is driven by an increase in RV pulsatile rather than resistive afterload. However, with the additive effects of increased RV resistive afterload, RV-PA uncoupling worsens dynamically during exercise.
Collapse
Affiliation(s)
- Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT
| | - Farbod N Rahaghi
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Robert Naeije
- Department of Pathophysiology, Erasmsus Campus, Brussels, Belgium
| | - Rudolf K F Oliveira
- Division of Respiratory Medicine, Federal University of São Paulo - UNIFESP, São Paulo, Brazil
| | - David M Systrom
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
| |
Collapse
|
10
|
Acute and Long-Term Effects of LVAD Support on Right Ventricular Function in Children with Pediatric Pulsatile Ventricular Assist Devices. ASAIO J 2018; 64:91-97. [PMID: 28509675 DOI: 10.1097/mat.0000000000000596] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Right ventricular failure (RVF) is a significant issue when considering left ventricular assist device (LVAD) implantation in pediatrics. The aim of this study was to evaluate the effects of LVAD on right ventricular (RV) function in children. We retrospectively reviewed clinical and echocardiographic data of children who underwent Berlin Heart EXCOR LVAD focusing on RV function before and after implantation (1, 3, and 6 month follow-up). An isolated LVAD was used in 27 patients. Median age was 11 months (interquartile range [IQR]: 5-24 months), with a median weight of 6.3 kg (IQR: 5-9 kg). Median time on ventricular assist device (VAD) support was 147 days (IQR: 86-210 days). Twenty patients were successfully bridged to orthotopic heart transplantation (OHT) (74%), six patients died (22%), and also heart function recovered in one patient (4%). Before LVAD implantation, nine patients (33%) showed a RV fractional area change (RVFAC) less than or equal to 30%. After implantation, mean RVFAC increased up until the 3 month follow-up (43.13%; p = 0.033) and then slightly decreased. In a subgroup of 18 patients, the average strain value increased after the 1 month follow-up (p = 0.022). Right ventricular failure developed in 33% of patients before the 1 month follow-up, and 7.4% experienced RVF at the 6 month follow-up. No patient required biventricular assist device (BiVAD). In our population, pulsatile-flow LVAD in children allows optimal RV decompression and function post-LVAD as measured by improvement in RV function at echo particularly at 1 and 3 month follow-up. At long-term follow-up, the beneficial effects of LVAD on RV function seem to be reduced as signs and symptoms of late RVF may develop in some patients despite LVAD support.
Collapse
|
11
|
Walpoth B, Mehan V, Rogulenko R, Aeschbacher B, Vucic G, Mettler D, Althaus U, Meier B. Left Heart Bypass in the Pig with a Centrifugal Pump Using Cannulae Prepared for Percutaneous Placement. Int J Artif Organs 2018. [DOI: 10.1177/039139889802100510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A rapid and efficient circulatory support system may save a patient in cardiogenic shock. Left heart bypass with percutaneous and trans-septal placement of the aspiration cannula simplifies the circuit and eliminates the need for an oxygenator. In this pre-clinical study we assessed left heart bypass support with a centrifugal pump using new cannulae prepared for percutaneous placement (14 F arterial catheter and 16 F left atrial aspiration line) in 5 anaesthetized pigs. Animals were supported for two hours at a mean flow of 3.2 l/min (4,033 rpm), a mean haematocrit of 29% and low heparinisation (ACT double baseline). Hemodynamic measurements and blood samples were taken at baseline (A), 10 minutes (B), one hour (C) and 2 hours (D) on support. Results show maintenance of hemodynamic parameters throughout the 2 hour support period. Only systolic arterial and left ventricular pressure decreased by 12% and 20% respectively from baseline to the end of the support period with a 13% increase in cardiac output. When the pump was turned on (0–3 l/min) there was usually a decrease in heart rate, systolic pressure and left ventricular pressure, with unchanged cardiac output (non failing model). Potassium increased from 3.9 to 4.2 mmol/l (ns), and plasma hemoglobin from 6.0 to 18.2 mg/dl (p<0.05). Thrombocytes decreased from 187 to 155 109/1 (ns). In conclusion, this preclinical study demonstrated the feasibility of an efficient left heart bypass of short duration with a centrifugal pump using cannulae prepared for percutaneous placement. Left heart bypass was well tolerated hemodynamically and no significant laboratory change occurred within the two hours of support. This opens several possibilities for the short term support of patients in cardiogenic shock and eventually also for patients submitted to minimally invasive cardiac surgery.
Collapse
Affiliation(s)
- B.H. Walpoth
- Department of Thoracic and Cardiovascular Surgery, University of Berne, Berne - Switzerland
| | - V. Mehan
- Department of Cardiology, University of Berne, Berne - Switzerland
| | - R. Rogulenko
- Department of Thoracic and Cardiovascular Surgery, University of Berne, Berne - Switzerland
| | - B. Aeschbacher
- Department of Cardiology, University of Berne, Berne - Switzerland
| | - G. Vucic
- Department of Surgical Research Unit, University of Berne, Berne - Switzerland
| | - D. Mettler
- Department of Surgical Research Unit, University of Berne, Berne - Switzerland
| | - U. Althaus
- Department of Thoracic and Cardiovascular Surgery, University of Berne, Berne - Switzerland
| | - B. Meier
- Department of Cardiology, University of Berne, Berne - Switzerland
| |
Collapse
|
12
|
Abe Y, Kotoh K, Deleuze P, Miyama M, Cooper G, Loisance D. Right Heart Function during Left Ventricular Assistance in an Open-Chest Porcine Model of Acute Right Heart Failure. Int J Artif Organs 2018. [DOI: 10.1177/039139889401700406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Changes in the right ventricular function measured with a thermodilution ejection fraction catheter have been recorded in open-chest normal pigs and pigs with acute right heart failure (RVF) undergoing left ventricular assistance with a pneumatic-sactype device (LVAD). To produce acute right heart failure, 5 pigs underwent ligation of the right ventricular free wall coronary arteries. Compared with normal pigs, cardiac output in ligated pigs fell by 21% (7.5 ± 0.5 vs 9.5 ± 1.2 L/min; p < 0.05) and the right ventricular end diastolic pressure rose (11.4 ± 2.6 vs 5.7 ± 3.6 vs mmHg: p <0.05). With the left ventricular assist device connected, the right atrial pressure was increased to 3, 5, 7, 10 and 12 mmHg by volume loading while maintaining the haematocrit at 35 ± 6%. The right ventricular stroke work index (RVSWI) increased with volume loading in normal pigs. In RVF pigs, RVSWI increased significantly with the LVAD (59.2 ± 5.8 vs 23.5 ± 7.8 mmHg ml/min/kg, p<0.01), approaching that of normal pigs (62.3 ± 4.8 mmHg ml/min/kg). Similar changes were observed in the cardiac output and right ventricular stroke volume. These results show that, in this model of open-chest, mild, acute right heart failure, left ventricular assistance allows right ventricular function to return to normal, despite volume overloading, by decreasing right ventricular after load and increasing right ventricular compliance
Collapse
Affiliation(s)
- Y. Abe
- Department of Surgical Research, C.N.R.S. URA 1431 Thérapeutiques Substitutives du Coeur et des Vaisseaux, Henri Mondor Hospital, University Paris XII - France
| | - K. Kotoh
- Department of Surgical Research, C.N.R.S. URA 1431 Thérapeutiques Substitutives du Coeur et des Vaisseaux, Henri Mondor Hospital, University Paris XII - France
| | - P.H. Deleuze
- Department of Surgical Research, C.N.R.S. URA 1431 Thérapeutiques Substitutives du Coeur et des Vaisseaux, Henri Mondor Hospital, University Paris XII - France
| | - M. Miyama
- Department of Surgical Research, C.N.R.S. URA 1431 Thérapeutiques Substitutives du Coeur et des Vaisseaux, Henri Mondor Hospital, University Paris XII - France
| | - G.J. Cooper
- Department of Surgical Research, C.N.R.S. URA 1431 Thérapeutiques Substitutives du Coeur et des Vaisseaux, Henri Mondor Hospital, University Paris XII - France
| | - D.Y. Loisance
- Department of Surgical Research, C.N.R.S. URA 1431 Thérapeutiques Substitutives du Coeur et des Vaisseaux, Henri Mondor Hospital, University Paris XII - France
| |
Collapse
|
13
|
Pinsky MR. The right ventricle: interaction with the pulmonary circulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:266. [PMID: 27613549 PMCID: PMC5018168 DOI: 10.1186/s13054-016-1440-0] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The primary role of the right ventricle (RV) is to deliver all the blood it receives per beat into the pulmonary circulation without causing right atrial pressure to rise. To the extent that it also does not impede left ventricular (LV) filling, cardiac output responsiveness to increased metabolic demand is optimized. Since cardiac output is a function of metabolic demand of the body, during stress and exercise states the flow to the RV can vary widely. Also, instantaneous venous return varies widely for a constant cardiac output as ventilatory efforts alter the dynamic pressure gradient for venous return. Normally, blood flow varies with minimal changes in pulmonary arterial pressure. Similarly, RV filling normally occurs with minimal increases in right atrial pressure. When pulmonary vascular reserve is compromised RV ejection may also be compromised, increasing right atrial pressure and limiting maximal cardiac output. Acute increases in RV outflow resistance, as may occur with acute pulmonary embolism, will cause acute RV dilation and, by ventricular interdependence, markedly decreased LV diastolic compliance, rapidly spiraling to acute cardiogenic shock and death. Treatments include reversing the causes of pulmonary hypertension and sustaining mean arterial pressure higher than pulmonary artery pressure to maximal RV coronary blood flow. Chronic pulmonary hypertension induces progressive RV hypertrophy to match RV contractility to the increased pulmonary arterial elastance. Once fully developed, RV hypertrophy is associated with a sustained increase in right atrial pressure, impaired LV filling, and decreased exercise tolerance. Treatment focuses on pharmacologic therapies to selectively reduce pulmonary vasomotor tone and diuretics to minimize excessive RV dilation. Owning to the irreversible nature of most forms of pulmonary hypertension, when the pulmonary arterial elastance greatly exceeds the adaptive increase in RV systolic elastance, due to RV dilation, progressive pulmonary vascular obliteration, or both, end stage cor pulmonale ensues. If associated with cardiogenic shock, it can effectively be treated only by artificial ventricular support or lung transplantation. Knowing how the RV adapts to these stresses, its sign posts, and treatment options will greatly improve the bedside clinician’s ability to diagnose and treat RV dysfunction.
Collapse
Affiliation(s)
- Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA. .,Department of Anesthesiology, University of California, East Campus Office Building, MC 7651, 9444 Medical Center Drive, Room 3-048, La Jolla, San Diego, CA, 92093, USA.
| |
Collapse
|
14
|
Pérez Del Villar C, Bermejo J, Rodríguez-Pérez D, Martínez-Legazpi P, Benito Y, Antoranz JC, Desco MM, Ortuño JE, Barrio A, Mombiela T, Yotti R, Ledesma-Carbayo MJ, Del Álamo JC, Fernández-Avilés F. The role of elastic restoring forces in right-ventricular filling. Cardiovasc Res 2015; 107:45-55. [PMID: 25691537 DOI: 10.1093/cvr/cvv047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 02/08/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS The physiological determinants of RV diastolic function remain poorly understood. We aimed to quantify the contribution of elastic recoil to RV filling and determine its sensitivity to interventricular interaction. METHODS AND RESULTS High-fidelity pressure-volume loops and simultaneous 3-dimensional ultrasound sequences were obtained in 13 pigs undergoing inotropic modulation, volume overload, and acute pressure overload induced by endotoxin infusion. Using a validated method, we isolated elastic restoring forces from ongoing relaxation using conventional pressure-volume data. The RV contracted below the equilibrium volume in >75% of the data sets. Consequently, elastic recoil generated strong sub-atmospheric passive pressure at the onset of diastole [-3 (-4 to -2) mmHg at baseline]. Stronger restoring suction pressure was related to a shorter isovolumic relaxation period, a higher rapid filling fraction, and lower atrial pressures (all P < 0.05). Restoring forces were mostly determined by the position of operating volumes around the equilibrium volume. By this mechanism, the negative inotropic effect of beta-blockade reduced and sometimes abolished restoring forces. During acute pressure overload, restoring forces initially decreased, but recovered at advanced stages. This biphasic response was related to alterations of septal curvature induced by changes in the diastolic LV-RV pressure balance. The constant of elastic recoil was closely related to the constant of passive stiffness (R = 0.69). CONCLUSION The RV works as a suction pump, exploiting contraction energy to facilitate filling by means of strong elastic recoil. Restoring forces are influenced by the inotropic state and RV conformational changes mediated by direct ventricular interdependence.
Collapse
Affiliation(s)
- Candelas Pérez Del Villar
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Javier Bermejo
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Daniel Rodríguez-Pérez
- Department of Mathematical Physics and Fluids, Facultad de Ciencias, Universidad Nacional de Educación a Distancia, Madrid, Spain
| | - Pablo Martínez-Legazpi
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain Mechanical and Aerospace Engineering Department, University of California San Diego, La Jolla, CA, USA
| | - Yolanda Benito
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - J Carlos Antoranz
- Department of Mathematical Physics and Fluids, Facultad de Ciencias, Universidad Nacional de Educación a Distancia, Madrid, Spain
| | - M Mar Desco
- Department of Mathematical Physics and Fluids, Facultad de Ciencias, Universidad Nacional de Educación a Distancia, Madrid, Spain
| | - Juan E Ortuño
- Biomedical Image Technologies, Universidad Politécnica de Madrid & CIBER-BBN, Madrid, Spain
| | - Alicia Barrio
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Teresa Mombiela
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Raquel Yotti
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Juan C Del Álamo
- Mechanical and Aerospace Engineering Department, University of California San Diego, La Jolla, CA, USA Institute for Engineering in Medicine, University of California San Diego, La Jolla, CA, USA
| | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| |
Collapse
|
15
|
Holman WL, Acharya D, Siric F, Loyaga-Rendon RY. Assessment and Management of Right Ventricular Failure in Left Ventricular Assist Device Patients. Circ J 2015; 79:478-86. [DOI: 10.1253/circj.cj-15-0093] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- William L. Holman
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham
| | - Deepak Acharya
- Division of Cardiovascular Disease, University of Alabama at Birmingham
| | - Franjo Siric
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham
| | | |
Collapse
|
16
|
Cho EJ, Jiamsripong P, Calleja AM, Alharthi MS, McMahon EM, Chandrasekaran K, Cha S, Bukatina AE, Khandheria BK, Belohlavek M. The Left Ventricle Responds to Acute Graded Elevation of Right Ventricular Afterload by Augmentation of Twist Magnitude and Untwist Rate. J Am Soc Echocardiogr 2011; 24:922-9. [DOI: 10.1016/j.echo.2011.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Indexed: 12/20/2022]
|
17
|
Toschi N, Guerrisi M. Interventricular coupling coefficients in a thick shell model of passive cardiac chamber deformation. Med Biol Eng Comput 2008; 46:637-48. [PMID: 18365264 DOI: 10.1007/s11517-008-0324-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Accepted: 02/19/2008] [Indexed: 10/22/2022]
Abstract
Mechanical interplay between the adjacent ventricles is one of the principal modulators of physiopathological heart function, and the underlying mechanisms of interaction are only partially understood, hence hampering clinically useful interpretation of imaging data. In order to characterize the influence of chamber geometry on ventricular coupling, the ventricles and septum are modeled as portions of ellipsoidal shells, and configuration is derived as a function of pressure gradients by combining shell element equilibrium equations through static boundary conditions applied at the sulcus. Diastolic volume (v) surfaces are calculated as a function of pressure (p), contralateral pressure (clp) and intrathoracic pressure (p ( t )) and match literature data where available. Ventricular interaction is characterized in terms of partial derivatives in v-p-clp-p ( t ) space both under physiological and altered (selectively stiffened walls) conditions. The model allows prediction of diastolic ventricular v-p-clp-p ( t ) interplay in a variety of physiopathological circumstances.
Collapse
Affiliation(s)
- N Toschi
- Sezione di Fisica Medica, Dipartimento di Biopatologia e Diagnostica per Immagini, Università Degli Studi di Roma Tor Vergata, Rome, Italy.
| | | |
Collapse
|
18
|
McBride LR, Naunheim KS, Fiore AC, Moroney DA, Swartz MT. Clinical experience with 111 thoratec ventricular assist devices. Ann Thorac Surg 1999; 67:1233-8; discussion 1238-9. [PMID: 10355389 DOI: 10.1016/s0003-4975(99)00246-5] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ventricular assist devices (VADs) have gained wider acceptance due to refinements in patient selection and management and device availability. METHODS To evaluate early and late results, we reviewed our first 111 patients with the Thoratec VAD. RESULTS Forty-four patients were supported for myocardial recovery. The mean age in the recovery group was 51.9 years. There were 18 left VADs (LVADs), 17 biventricular VADs (BVADs), and nine right VADs (RVADs). Complications included bleeding in 20 patients (45%) and device-related infection in 1 patient (2%). Nineteen were weaned from the VAD, with 12 survivors. Sixty-seven patients were supported as a bridge to cardiac transplantation. The mean age was 41.5 years. There were 39 LVADs and 28 BVADs. Complications included bleeding in 21 patients (31%) and device-related infection in 12 (18%). Three patients were weaned and 39 patients were transplanted from the assist device, for a total of 42 bridge survivors. Device-related thromboembolism occurred in 9 patients (8.1%), 7 of whom were bridge to transplantation. The duration of VAD support ranged from 0.1 to 27 days (mean 4.5 days) in the recovery group and 0.2 to 184 days (mean 40.7 days) in the bridge to transplantation group. The 10-year actuarial survival was 16% for the recovery group, 22%, for the bridge group, and 33% for transplanted patients. CONCLUSIONS Despite advances, VAD support remains associated with significant morbidity and operative mortality.
Collapse
Affiliation(s)
- L R McBride
- Department of Surgery, Saint Louis University, Missouri 63110-0250, USA.
| | | | | | | | | |
Collapse
|
19
|
Argenziano M, Choudhri AF, Moazami N, Rose EA, Smith CR, Levin HR, Smerling AJ, Oz MC. Randomized, double-blind trial of inhaled nitric oxide in LVAD recipients with pulmonary hypertension. Ann Thorac Surg 1998; 65:340-5. [PMID: 9485226 DOI: 10.1016/s0003-4975(97)01307-6] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pulmonary vascular resistance is often elevated in patients with congestive heart failure, and in those undergoing left ventricular assist device (LVAD) insertion, it may precipitate right ventricular failure and hemodynamic collapse. Because the effectiveness of inotropic and vasodilatory agents is limited by systemic effects, right ventricular assist devices are often required. Inhaled nitric oxide (NO) is an effective, specific pulmonary vasodilator that has been used successfully in the management of pulmonary hypertension. METHODS Eleven of 23 patients undergoing LVAD insertion met criteria for elevated pulmonary vascular resistance on weaning from cardiopulmonary bypass (mean pulmonary artery pressure > 25 mm Hg and LVAD flow rate < 2.5 L x min[-1] x m[-2]) and were randomized to receive either inhaled NO at 20 ppm (n = 6) or nitrogen (n = 5). Patients not manifesting a clinical response after 15 minutes were given the alternative agent. RESULTS Hemodynamics for the group at randomization were as follows: mean arterial pressure, 72 +/- 6 mm Hg; mean pulmonary artery pressure, 32 +/- 4 mm Hg; and LVAD flow, 2.0 +/- 0.3 L x min(-1) x m(-2). Patients receiving inhaled NO exhibited significant reductions in mean pulmonary artery pressure and increases in LVAD flow, whereas none of the patients receiving nitrogen showed hemodynamic improvement. Further, when the nitrogen group was subsequently given inhaled NO, significant hemodynamic improvements ensued. There were no significant changes in mean arterial pressure in either group. CONCLUSIONS Inhaled NO induces significant reductions in mean pulmonary artery pressure and increases in LVAD flow in LVAD recipients with elevated pulmonary vascular resistance. We conclude that inhaled NO is a useful intraoperative adjunct in patients undergoing LVAD insertion in whom pulmonary hypertension limits device filling and output.
Collapse
Affiliation(s)
- M Argenziano
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA.
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Santamore WP, Dell'Italia LJ. Ventricular interdependence: significant left ventricular contributions to right ventricular systolic function. Prog Cardiovasc Dis 1998; 40:289-308. [PMID: 9449956 DOI: 10.1016/s0033-0620(98)80049-2] [Citation(s) in RCA: 353] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This article reviews diastolic and systolic ventricular interaction, and clinical pathophysiological conditions involving ventricular interaction. Diastolic ventricular interdependence is present on a moment-to-moment, beat-to-beat basis, and the interactions are large enough to be of physiological and pathophysiological importance. Although always present, ventricular interdependence is most apparent with sudden postural and respiratory changes in ventricular volume. Left ventricular function significantly affects right ventricular systolic function. Experimental studies have shown that about 20% to 40% of the right ventricular systolic pressure and volume outflow result from left ventricular contraction. This dependency of the right ventricle on the left ventricle helps to explain the right ventricular response to volume overload, pressure overload, and myocardial ischemia. The septum and its position are not the sole mechanism for ventricular interdependence. Ventricular interdependence causes overall ventricular deformation, and is probably best explained by the balance of forces at the interventricular sulcus, the material properties, and cardiac dimensions.
Collapse
Affiliation(s)
- W P Santamore
- Jewish Hospital Cardiothoracic Surgical Research Institute, Division of Thoracic and Cardiovascular Surgery, University of Louisville, KY 40292, USA
| | | |
Collapse
|
21
|
Slater JP, Lipsitz EC, Chen JM, Levin HR, Oz MC, Goldstein DJ, Ashton RC, Burkhoff D. Systolic ventricular interaction in normal and diseased explanted human hearts. J Thorac Cardiovasc Surg 1997; 113:1091-9. [PMID: 9202690 DOI: 10.1016/s0022-5223(97)70296-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to quantify the magnitude of interaction between the right and left ventricles in conditions of heart failure. METHODS Human hearts were taken from transplant recipients diagnosed with diluted cardiomyopathy at the time of transplantation and were restored to beating condition with use of an isolated perfusion circuit. Left ventricular-right ventricular interaction was determined by ramping volume in the left ventricle while holding right ventricular volume constant. Right ventricular pressure gain was plotted against left ventricular pressure and the slope of the linear regression determined the left ventricular-right ventricular interaction. A similar procedure was used to determine right ventricular-left ventricular interaction. Two normal hearts were obtained from transplant donors not suitable for cardiac donation to serve as control hearts. RESULTS Mean left ventricular-right ventricular interaction was 0.22 in the hearts with dilated cardiomyopathy compared with 0.06 in the control hearts. Mean right ventricular-left ventricular interaction was 0.14 in the hearts with dilated cardiomyopathy compared with 0.09 in the control hearts. A marked increase in left ventricular-right ventricular interaction was noted in the hearts with dilated cardiomyopathy compared with control hearts. Although observed values of right ventricular-left ventricular interaction also correspond to previously published results, no significant increase was observed in the dilated cardiomyopathy condition. CONCLUSIONS These studies confirm previously published values for systolic ventricular interaction obtained with animal models and demonstrate a marked increase in the dependence of the right ventricle on left ventricular function to maintain systolic pressure generation during conditions of dilated cardiomyopathy.
Collapse
Affiliation(s)
- J P Slater
- Department of Surgery (Division of Cardiothoracic Surgery), Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Farrar DJ, Hill JD, Pennington DG, McBride LR, Holman WL, Kormos RL, Esmore D, Gray LA, Seifert PE, Schoettle GP, Moore CH, Hendry PJ, Bhayana JN. Preoperative and postoperative comparison of patients with univentricular and biventricular support with the thoratec ventricular assist device as a bridge to cardiac transplantation. J Thorac Cardiovasc Surg 1997; 113:202-9. [PMID: 9011691 DOI: 10.1016/s0022-5223(97)70416-1] [Citation(s) in RCA: 168] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The goal of this study was to determine whether there are differences in populations of patients with heart failure who require univentricular or biventricular circulatory support. METHODS Two hundred thirteen patients who were in imminent risk of dying before donor heart procurement and who received Thoratec left (LVAD) and right (RVAD) ventricular assist devices at 35 hospitals were divided into three groups: group 1 (n = 74), patients adequately supported with isolated LVADs; group 2 (n = 37), patients initially receiving an LVAD and later requiring an RVAD; and group 3 (n = 102), patients who received biventricular assistance (BiVAD) from the beginning. RESULTS There were no significant differences in any preoperative factors between the two BiVAD groups. In the combined BiVAD groups, pre-VAD cardiac index (BiVAD, 1.4 +/- 0.6 L/min per square meter, vs LVAD, 1.6 +/- 0.6 L/min per square meter) and pulmonary capillary wedge pressure (BiVAD, 27 +/- 8 mm Hg, vs LVAD, 30 +/- 8 mm Hg) were significantly lower than those in the LVAD group, and pre-VAD creatinine levels were significantly higher (BiVAD, 1.9 +/- 1.1 mg/dl, vs LVAD, 1.4 +/- 0.6 mg/dl). In addition, greater proportions of patients in the BiVAD groups required mechanical ventilation before VAD placement (60% vs 35%) and were implanted under emergency conditions than in the LVAD group (22% vs 9%). The survival of patients through heart transplantation was significantly better in patients who had an LVAD (74%) than in those who had BiVADs (58%). However, there were no significant differences in posttransplantation survival through hospital discharge (LVAD, 89%; BiVAD, 81%). CONCLUSION Patients who received LVADs were less severely ill before the operation and consequently were more likely to survive after the operation. As the severity of illness increases, patients are more likely to require biventricular support.
Collapse
Affiliation(s)
- D J Farrar
- California Pacific Medical Center, San Francisco 94115, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Abstract
BACKGROUND In patients with postcardiotomy low cardiac output syndromes, right ventricular (RV) failure develops in approximately 25% of patients receiving left ventricular (LV) assist device support. Depressed RV function have been attributed to abnormalities of the RV myocardium, excessive load imposed on the RV during systole or diastole, or obstruction to RV inflow. However, recent studies also suggest that LV function may significantly affect RV function through ventricular interdependence. METHODS We reviewed the data showing the importance of systolic ventricular interaction. We then related these observations to the RV response during LV assist device support, and present our ideas regarding the mechanisms responsible for this RV failure. RESULTS Using an electrically isolated right heart preparation, Damiano observed double-peaked waveforms for RV pressure, and pulmonary artery blood flow occurred over a wide range (0 to 300 ms) of pacing intervals between the LV and RV. Numeric analysis indicated that RV systolic pressure and pulmonary artery blood flow were composed of both RV and LV components, with the LV component dominating (63.5% versus 36.5%). CONCLUSIONS The experimental studies indicate a very consistent RV response during LV assist device support: a decrease in RV afterload, increased compliance, and decreased contractility. In normal hearts, the net effect is an increase or no change in cardiac output. With a preexisting pathologic condition, the RV responses is qualitatively the same, but anatomic ventricular interaction is accentuated, leading to a greater decrease in RV contractility. The net effect is a decrease in cardiac output, which may require inotropic or RV mechanical support.
Collapse
Affiliation(s)
- W P Santamore
- Division of Thoracic and Cardiovascular Surgery, University of Louisville, Kentucky 40292, USA
| | | |
Collapse
|
24
|
Abstract
Right ventricular failure unresponsive to pharmacologic treatment occurs in approximately 20% to 30% of patients supported with a left ventricular assist device (LVAD). The effect of the assistance on right ventricular function is highly controversial. Increased venous return produced by an LVAD can affect right ventricular function by increasing preload. On the other hand, an LVAD can improve the filling of the right ventricle by unloading the left ventricle, reducing its chamber size and shifting the septum back to the left. Right ventricular function is highly afterload dependent, the ventricular function depending on the pulmonary vascular resistance. With a normal pulmonary vascular bed, the LVAD can improve right ventricular function by reducing right ventricular afterload. If there is a fixed high pulmonary pressure, however, the LVAD can increase right ventricular afterload and volume. We conclude that the right ventricle is dispensable if the pulmonary vascular bed is normal.
Collapse
Affiliation(s)
- A Pavie
- Department of Thoracic and Cardiovascular Surgery, La Pitie Hospital, Paris, France
| | | |
Collapse
|
25
|
Santamore WP, Gray L. Significant left ventricular contributions to right ventricular systolic function. Mechanism and clinical implications. Chest 1995; 107:1134-45. [PMID: 7705127 DOI: 10.1378/chest.107.4.1134] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- W P Santamore
- Division of Thoracic and Cardiovascular Surgery, University of Louisville, Ky 40202, USA
| | | |
Collapse
|
26
|
Kitano M, Nishimura K, Hee PC, Okamoto Y, Ban T. Right ventricular function evaluated by volumetric analysis during left heart bypass in a canine model of postischemic cardiac dysfunction. J Thorac Cardiovasc Surg 1995; 109:796-803. [PMID: 7715229 DOI: 10.1016/s0022-5223(95)70363-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Right ventricular function during left heart bypass was evaluated by volumetric analysis with a conductance catheter in 12 dogs with postischemic cardiac dysfunction. The conductance catheter was used to assess the volumetric status of the right ventricle and thereby allowed a right ventricular pressure-volume curve to be obtained, in which transient volume loading on the right ventricle was applied. The following right ventricular properties during left heart bypass were assessed and compared with properties measured without left heart bypass, by means of load-independent parameters: maximum elastance, stroke work/end-diastolic volume relation, end-diastolic pressure/volume relation, and stroke work/end-diastolic pressure relation. The stroke volume derived from the conductance catheter and the electromagnetic flow probe showed good linear correlation (r2 = 0.733 to 0.975). After initiation of left heart bypass, maximum elastance did not change significantly, although volume intercept significantly increased, from 1.2 +/- 7.3 to 3.6 +/- 7.9 ml (p < 0.05). End-diastolic pressure/volume relation was well fitted to the exponential curve (EDP = e(k1.EDV+k2)) and was shifted to the right and downward during left heart bypass; the slope k1 significantly decreased, from 0.12 +/- 0.06 to 0.10 +/- 0.07 (p < 0.01). Stroke work/end-diastolic volume relation and stroke work/end-diastolic pressure relation were closely fitted to the linear regression, and their slopes were significantly increased during left heart bypass, from 0.14 +/- 0.08 to 0.18 +/- 0.08 (p < 0.05) and from 0.22 +/- 0.15 to 0.34 +/- 0.19 (p < 0.01), respectively. These results suggest that the decompression of the left ventricle and septal shifting by left heart bypass provide good diastolic compliance and good systolic performance because of afterload unloading of the right ventricle. Thus the left heart bypass improved the overall right ventricular performance, particularly at higher end-diastolic pressures, in dogs with postischemic cardiac dysfunction.
Collapse
Affiliation(s)
- M Kitano
- Department of Cardiovascular Surgery, Kyoto University Faculty of Medicine, Japan
| | | | | | | | | |
Collapse
|
27
|
Yamaguchi S, Li KS, Harasawa H, Santamore WP. Acute alterations in systolic ventricular interdependence-mechanical dependence of right ventricle on left ventricle following acute alteration of right ventricular free wall. Basic Res Cardiol 1993; 88:350-61. [PMID: 8240227 DOI: 10.1007/bf00800641] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The purpose of the study was to examine whether systolic ventricular interdependence can be acutely altered by changes in the mechanical properties of the ventricular wall. In eight acute canine studies, we released an aortic constriction during diastole. We measured right ventricular (RV) pressure changes (dPr) caused by sudden changes in left ventricular (LV) pressure (dPl). Measurements were obtained during control, 10 min after right coronary artery occlusion, and then 15 min after injecting glutaraldehyde into the RV free wall. By superimposing the pressure tracings of the beats immediately before and after the aortic release, the instantaneous pressure difference ratio (dPr/dPl) was calculated during systole. Maximal value of the pressure difference ratio decreased from control 0.11 +/- 0.04 to ischemia 0.08 +/- 0.03; (p < 0.05) and increased with glutaraldehyde 0.15 +/- 0.06; (p < 0.05). Thus, acute ischemia in RV free wall decreased the magnitude of systolic ventricular interdependence from LV to RV, while glutaraldehyde, which stiffens the RV free wall, increased the magnitude.
Collapse
Affiliation(s)
- S Yamaguchi
- First Department of Internal Medicine, Yamagata University School of Medicine, Japan
| | | | | | | |
Collapse
|
28
|
Right heart function during prosthetic left ventricular assistance in a porcine model of congestive heart failure. J Thorac Cardiovasc Surg 1992. [DOI: 10.1016/s0022-5223(19)34720-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|