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Dr. Pascal De Groote,
The evaluation of the right ventricular (RV) function is complex and the management of patient with right heart diseases is difficult. In order to evaluate RV function, we need to take into account different parameters. Professor Gibbs gives us a complete overview of the impact of RV dysfunction on prognosis in several diseases. Several studies have demonstrated that the RV ejection fraction (RVEF) was a powerful independent predictor of survival in patients with chronic left ventricular systolic dysfunction. However, other parameters must be evaluated in combination with RVEF. Elevated pulmonary pressure, important RV dilatation, severe tricuspid regurgitation are also other important prognostic markers. Finally, the evolution of RV function must be followed because a worsening in RVEF is clearly related to survival. The interesting presentation of Professor Klautz tried to answer to an important clinical question: when is tricuspid valve surgery required in combination with a left side intervention? The incidence of recurrent tricuspid regurgitation (TR) after mitral valve surgery is close to 8% and this recurrence has a negative impact on survival. Predictors of TR recurrence were the presence of atrial fibrillation, peak velocity of the TR and the diameter of the tricuspid annulus. Tricuspid repair in patients with a moderate TR (< grade 3) and a dilated tricuspid annulus measured by echocardiography (≥ 40 mm) was associated after 2 years of follow-up with an improvement in RV function, with a decrease in pulmonary pressure and in RV dilatation compared to patients not having tricuspid repair. It is important to measure the diameter of the tricuspid annulus in all patients selected for left heart valve surgery. Tricuspid repair must be considered when the tricuspid annulus is ≥ 40 mm. Finally, Professor Lang from Vienna gave us a very elegant presentation concerning the surgical treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary endarterectomy gives us the possibility to cure patients with CTEPH. However, it is a complex and difficult surgery and the perioperative mortality and success rates are correlated to the experience of the centre. The perioperative mortality rate is close to 5% in experimented centres (more than 50 interventions per year). Moreover, the operability is also related to the experience of the centre. The most important cause of non operability is inaccessibility of the thrombo-embolic material. Of particular interest, age is not a cause of non operability because the success of the surgery is similar whatever the age of the patients. Currently, there are no recommended specific drugs for these patients and all patients with CTEPH must be assessed for surgery in experimented centres. These three different presentations showed us the complexity of the right side of the heart. The phenotype of right ventricular diseases is different. The right ventricle of patients with left ventricular systolic dysfunction could not be compared to the RV of patients with pulmonary hypertension, mitral valve disease or congenital heart disease. RV adaptation to pressure or volume overload is different. Further studies in selected populations are required in order to better understand the pathophysiology of the right ventricle and to improve the clinical management of these patients.
From bench to practice: highlights from the right side of the heart
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