RV function Prognostic implications in heart failure

41
RV function Prognostic implications in heart failure Efthimios Anagnostou M.D.

description

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. - PowerPoint PPT Presentation

Transcript of RV function Prognostic implications in heart failure

Page 1: RV function Prognostic implications in heart failure

RV functionPrognostic implications in heart failure

Efthimios Anagnostou M.D.

Page 2: RV function Prognostic implications in heart failure

No disclosures

Page 3: RV function Prognostic implications in heart failure

After AMI

Congestive HF

Valvular HD

Congenital HD

After HT

Pulmonary Embolism

Pulmonary HTN

HFpEF

The prognostic value of RV function in cardiovascular disease.

Page 4: RV function Prognostic implications in heart failure

Courtesy C.Celton-Saty

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

Page 5: RV function Prognostic implications in heart failure

RVEF predicts prognosis in CHF

Page 6: RV function Prognostic implications in heart failure

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%

Page 7: RV function Prognostic implications in heart failure

Better survival & Better exercise capacity

Page 8: RV function Prognostic implications in heart failure

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

Page 9: RV function Prognostic implications in heart failure

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

Page 10: RV function Prognostic implications in heart failure

RV dysfunction portends an

inferior survival.

• variations in study populations,

• severity and substrates of disease,

• methodologies of assessment.

Despite…

Page 11: RV function Prognostic implications in heart failure

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;163:1212–823. 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…

Page 12: RV function Prognostic implications in heart failure

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%

Page 13: RV function Prognostic implications in heart failure

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

Page 14: RV function Prognostic implications in heart failure

The commonest cause of RV Dysfunction is Left Heart Disease

LV Systolic DysfunctionCADValve Disease

LV Diastolic Dysfunction Hypertension

Restrictive CardiomyopathyHCM

HFrEF

HFpEF

Page 15: RV function Prognostic implications in heart failure

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

Page 16: RV function Prognostic implications in heart failure

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

Page 17: RV function Prognostic implications in heart failure

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

Page 18: RV function Prognostic implications in heart failure

Different Hemodynamic Stages in GROUP 2 PH

Page 19: RV function Prognostic implications in heart failure

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

Page 20: RV function Prognostic implications in heart failure

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

Page 21: RV function Prognostic implications in heart failure

PAP

PCWP

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

Mechanism of PH in CHF

Page 22: RV function Prognostic implications in heart failure

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

Page 23: RV function Prognostic implications in heart failure

ADULT HEART TRANSPLANTATIONKaplan Meyer estimates of mortality 1999-2007

stratified by PVR

< 2 WU2- 4 WU> 4 WU

Page 24: RV function Prognostic implications in heart failure

Ventricular Interdependence

Page 25: RV function Prognostic implications in heart failure

Wolferen, EHJ 2007

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

Page 26: RV function Prognostic implications in heart failure

RV failure

RV dilatation

RVH

D-shaped LV

RA dilatation

TricuspidRegurgitation

Page 27: RV function Prognostic implications in heart failure

This is the end, my friendThis is the beginning

The shrinking LV…

Page 28: RV function Prognostic implications in heart failure

HFpEF

Page 29: RV function Prognostic implications in heart failure
Page 30: RV function Prognostic implications in heart failure

PASP estimates are a risk factor for death.

Page 31: RV function Prognostic implications in heart failure
Page 32: RV function Prognostic implications in heart failure

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?

Page 33: RV function Prognostic implications in heart failure

We would be poorly served by buying

into the concept that an RVEF is the

only ‘‘reference standard,’’ without

recognition of its shortcomings.

Page 34: RV function Prognostic implications in heart failure

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.

Page 35: RV function Prognostic implications in heart failure

When grappling with what measure

should be adopted to evaluate RV

systolic function, we are left with the

classic answer:

it depends!

Page 36: RV function Prognostic implications in heart failure

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

Page 37: RV function Prognostic implications in heart failure

Thank you

Page 38: RV function Prognostic implications in heart failure
Page 39: RV function Prognostic implications in heart failure
Page 40: RV function Prognostic implications in heart failure
Page 41: RV function Prognostic implications in heart failure

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