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Structural heart disease: right ventricle

Joint session with the ESC Working Groups on Grown-up Congenital Heart Disease, the ESC Working Group on Cardiovascular Magnetic Resonance and the ESC Working Group on Nuclear Cardiology and Cardiac Computed Tomography.

Dr Friedberg opened the session with the talk entitled “Imaging and physiology: is the right ventricle doomed to fail?” He discussed right ventricular (RV) physiology and mechanisms for RV failure in conditions of RV abnormal afterload and preload. He demonstrated how the physiology of the normal RV is different from the left ventricle (LV) and how the RV adapts through molecular mechanisms, remodeling, hypertrophy, contraction patterns and how this is reflected in a change to a LV type pressure-volume loop in RV adaptation without RV failure. Concomitantly, there can be development of RV fibrosis, which in various conditions such as Tetralogy of Fallot, impacts regional and global function, as well as clinical outcomes. He stressed the need to investigate use of various imaging techniques for earlier detection of RV failure; this could lead to earlier intervention for improved outcomes.
Dr Simpson followed with ‘Is 2D echo obsolete?’ He showed the multitude of different modalities and available indices for the assessment of RV function and pointed out that not all techniques are used in every patient in every situation. Dr Simpson highlighted the recent pediatric guidelines that include RV quantification, but emphasized the lack of normal reference data, even for simple measurements. He stressed the need to tailor imaging to the individual patient based on the clinical scenario and questions at hand. He showed how cardiac magnetic resonance (CMR) is advantageous compared to echocardiography for the assessment of RV volumes, especially in congenital heart disease, as 3D echocardiography has been found to underestimate RV volumes compared to CMR, sometimes significantly. These assessments then influence clinical decision making.
He showed new developments in 3D echocardiography that may improve assessment of RV volumes and ejection fraction. However, he stressed that it is not RV volumes alone that determine clinical course and the need for intervention; and that echo has a major role to play in assessing the physiology of the individual patient. Therefore, using multiple modalities to utilize the strengths of each to answer the clinical question is important. Finally, more research is needed linking the imaging results with clinical outcomes to get a better handle on their clinical significance.
Dr Valsangiacomo Buechel, who gave the talk ‘Does MRI/ CT lead the dance’ reiterated that 3D echo underestimates RV volumes and that MRI can estimate RV volumes with good reproducibility. She emphasized the use of short axis images to assess volumes. She showed how in patients with congenital heart disease, a single MRI examination can provide information on multiple questions such as anatomical stenosis, valvar morphology, pulmonary blood flow, RV function and RV fibrosis. She spoke about new developments for fibrosis imaging, including T1 weighted imaging, as well as new applications of MRI, such as systemic RV assessment during stress.
Dr Le Tourneau spoke on the topic ‘Do therapeutic options exist when the right ventricle fails?’ He demonstrated how in multiple situations, treatment of the underlying cause for RV failure can alleviate RV dysfunction. He further pointed out that RV failure is often reversible and the RV can reverse remodel. He gave various examples, including increased afterload, such as in pulmonary hypertension, increased pre-load, such as after tetralogy of Fallot with pulmonary regurgitation, and interestingly, in atrial fibrillation, as well as in organic mitral regurgitation. He emphasized that beyond treating the underlying cause, other heart failure medications used in LV failure have not been proven efficacious in the failing RV. He showed how there may be potential for use of cardiac resynchronization therapy in some patients with RV failure and RV dyssynchrony.




Structural heart disease: right ventricle

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.

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