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Right ventricular dysfunction and failure

ESC Congress 2010

Heart Failure (HF)


There is an increasing interest in right ventricular dysfunction and right ventricular failure.

The causes of right heart failure, as reported by Dr Monserrat (Coruna,Es), can be different. They can be by dysfunction of RV myocardium (RV myocardial infarction, arrhythmogenic right ventricular cardiomyopathy etc ), by pressure overload (LV heart failure, mitral valve disease, cor pulmonale etc ), by volume overload (pulmonary regurgitation , atrial septal defect etc), by right ventricular inflow obstruction (RV infarction ,tricuspid stenosis, cardiac tamponade, restrictive cardiomyopathy etc).

The pathophysiology of the right ventricle was presented by Dr Torbicki (Warsaw,PL). In this interesting talk, he presented the pressure volume curve in normal patients and in patients with right heart failure. Pulmonary hypertension can give pressure overload but also a reduction in coronary flow. Maintaining coronary flow to the RV is crucial, especially when RV pressure is elevated. In chronic pulmonary disease for increased after-load muscular hypertrophy, right ventricular dilatation, intrinsic myocardial alterations develop and RV end-diastolic and right atrial pressures rise.

The assessment of right ventricular function is possible with study of morphology (shape, volume, mass, eccentric index) and function. Dr Vachiery from Brussels presented different techniques. Unlike the LV, where biplane methods are accepted and widely used for global assessment of systolic function, a quantitative approach to evaluating RV global function is more difficult for complex shape. Surrogate parameters were developed and validated against EF derived by isotopic methods or MRI. Area change in four chambers, right ventricular outflow tract shortening (RVOT-SF), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI) are used in this field. Novel methods include: pulsed DMI (simple to use online and has very good temporal resolution), myocardial isovolumetric acceleration (IVA) (less dependent on loading conditions), Strain and Strain rate (good results in pulmonary hypertension, arrhythmogenic right ventricular cardiomyopathy).

The therapeutic approach is based on established therapy and in novel therapeutic ways presented by Dr Rosenkranz from Koeln. During the last years, therapeutic options for the treatment of pulmonary arterial hypertension have significantly improved .Three drugs classes are approved for treatment: endothelin receptor antagonists, phosphodiesterase type 5 inibitors, prostanoids. These treatments lead to modest regression of RV hypertrophy (indirect effect). Diminished energy metabolism may be an important process in maladaptive RV hypertrophy. We await new drugs such as guanylate cyclase stimulators (NO-independent vasodilatation), tyrosine kinase inhibitors, sorafenib (antiproliferative drugs that inhibit or may reverse the pulmonary vascular remodeling process), serotonin receptor antagonists (anti proliferative, antithrombotic and anti-fibrotic effects).

The symposium was very interesting with all seats occupied all the time.

References


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Right ventricular dysfunction and failure
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.