RV functionPrognostic implications in heart failure

Efthimios Anagnostou M.D.

No disclosures

After AMI

Congestive HF

Valvular HD

Congenital HD

After HT

Pulmonary Embolism

Pulmonary HTN

HFpEF

The prognostic value of RV function in cardiovascular disease.

Courtesy C.Celton-Saty

reduced RVEF is an independent prognostic factor in moderate to severe CHF.

RVEF predicts prognosis in CHF

Larose

147Pts, late after MI , RVEF<40%

CMR RVEF and survival @ 17 months

Larose JACC 2007

RVEF: Prognostic impact late after AMI

RVEF<40%

RVEF≥40%

Better survival & Better exercise capacity

RV function + PH predict survival in CHF

Ghio, JACC 2001

379 CHF pts, LVEF<35% ,DCM & IHD, optimized Rx RHC with thermodilution RVEF

Normal PAP +Normal RVEF

High PAP +Low RVEF

RV dilatation predicts survival in CHF380 CHF pts, LVEF<45% VS controls

DILATED RV IN 25% of ptsRVESVi: independent predictor of mortality

Bourantas EJHF 2011

RV dysfunction portends an

inferior survival.

• variations in study populations,

• severity and substrates of disease,

• methodologies of assessment.

Despite…

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RV dysfunction

Bibliography

30 years ago …

Insidiously ignored until the BEST trial…

distribution of RVEF in CHF2008 pts, from the BEST study, LVEF<35%,NYHA III/IV

Radionuclide RVEF and mortality @ 24 months

Meyer et al, Circulation 2012

Mortality 47% Mortality 27%

=63% =37%

What is RV failure ?

Inability of the RV to maintain cardiac output through the pulmonary vascular bed at normal central venous pressures.

an Increased Preload (RA pressure) is

required to maintain adequate CO

The commonest cause of RV Dysfunction is Left Heart Disease

LV Systolic DysfunctionCADValve Disease

LV Diastolic Dysfunction Hypertension

Restrictive CardiomyopathyHCM

HFrEF

HFpEF

HTN

HFpEFHFrEF

MV disease

AoV disease

LA pressure

CHF causes Pulmonary Hypertension leading to Right Ventricular Failure

PCWP

Group 2 PHmPA>25mmHg PCWP >15mmHg CO normal or low

PAP

1000 CHF pts undergoing transplant evaluation

Correlation nice and straight and fairly tight indicating therefore that PAP is driven passively by PCWP

Mechanism of PH in CHF

Drazner J Heart Lung Transplant 1999

PAP

PCWP

intimal Fibrosis

This may or may not result in rise in the PAP with a consequent rise in the TPG or PVR

Mechanism of PH in CHF

Different Hemodynamic Stages in GROUP 2 PH

Drazner J Heart Lung Transplant 1999

1000 CHF pts undergoing transplant evaluation

Mechanism of PH in CHF

because of vascular changes in the arterial side of pulmonary circulation

Out of

propo

rtion P

H

CHF, PH-CHF, PH+

 Marked medial hypertrophy of a muscular pulmonary artery in a patient with CHF, compared to another of similar size with minimal medial thickening in a patient with

CHF but not pulmonary hypertension

This is NOT, however, idiopathic PAH (a vascular proliferative disease) but rather a secondary medial hypertrophy of the pulmonary arteries

A RESPONSE TO PREVENT ALVEOLAR EDEMA FROM HAPPENING

PAP

PCWP

As a consequence of rise in PAP, PVR and PVH, the RV runs into trouble

Mechanism of PH in CHF

PH and impaired Exercise capacity in CHF

Di Salvo JACC 1995

320 pts

a consequence of rise in PVR is the dramatic decrease in CO both at rest and during exercise

ADULT HEART TRANSPLANTATIONKaplan Meyer estimates of mortality 1999-2007

stratified by PVR

< 2 WU2- 4 WU> 4 WU

Ventricular Interdependence

Wolferen, EHJ 2007

RV stroke volume predicts prognosis in PAH 64 pts, CMR, RHC, 6MWT

RV failure

RV dilatation

RVH

D-shaped LV

RA dilatation

TricuspidRegurgitation

This is the end, my friendThis is the beginning

The shrinking LV…

HFpEF

PASP estimates are a risk factor for death.

Markers of RV Dysfunction associated with clinical status and prognosis

Systolic Performance RVEFRVFACTAPSERV MPIHemodynamicsRA pressureCIMaximal dP/dTPressure–volume MeasurementsVentricular elastancePreload recruitable stroke work

Diastolic FillingTissue Doppler indicesIsovolumic accelerationSyst/Diast myocardial velocitiesRight-sided DilationRV dilation absolute/ relative to LVRA sizeTR

Which?

We would be poorly served by buying

into the concept that an RVEF is the

only ‘‘reference standard,’’ without

recognition of its shortcomings.

Sugeng, J A C C i m g 2 0 1 0

Multimodality Comparison of Quantitative Volumetric Analysis of the Right Ventricle

However, our results also showed that RV volume measurements are not interchangeable between modalities and, therefore, serial evaluations should be performed using the same modality.

When grappling with what measure

should be adopted to evaluate RV

systolic function, we are left with the

classic answer:

it depends!

RV dysfunction is a strong parameter of functional capacity

RV dysfunction is prognostically superior to LV parameters of systolic/diastolic function

RV dysfunction is present in about two-thirds of patients with CCF and doubles mortality

RV dilatation has the worst prognosis

RV assessment is a must of the diagnostic work-up in CCF patients

Conclusions

Thank you

The  myocardium of the  entire heart is now known to be a

single sheet of muscle rolled into different chambers 

http://www.youtube.com/watch?v=Mih37LLv6IQ&feature=plcp