Right heart failure in pulmonary hypertension: Diagnosis and new perspectives on vascular and direct right ventricular treatment

The functional relevance of right atrial (RA) function in pulmonary hypertension (PH) remains incompletely understood. The purpose of this study was to explore the correlation of cardiac magnetic resonance (CMR) feature tracking-derived RA phasic function with invasively measured pressure-volume (P-V) loop-derived right ventricular (RV) end-diastolic elastance ( Eed) and RV-arterial coupling [ratio of end-systolic elastance to arterial elastance ( Ees/ Ea)]. In 54 patients with severe PH, CMR was performed within 24 h of diagnostic right heart catheterization and P-V measurements. RA phasic function was assessed by CMR imaging of RA reservoir, passive, and active strain. The association of RA phasic function with indexes of RV function was evaluated by Spearman’s rank correlation and linear regression analyses. Median [interquartile range] RA reservoir strain, passive strain, and active strain were 19.5% [11.0–24.5], 7.0% [4.0–12.0], and 13.0% [7.0–18.5], respectively. Ees/ Ea was 0.73 [0.48–1.08], and Eed was 0.14 mmHg/mL [0.05–0.22]. RV diastolic impairment [RV end-diastolic pressure (EDP) and Eed] was correlated with RA phasic function, but Ea and Ees were not. In addition, RA phasic function was correlated with inferior vena cava diameter. In multivariate linear regression analysis, adjusting for key P-V loop indexes, Eed and EDP remained significantly associated with RA phasic function. We conclude that RA phasic function is altered in relation to impaired diastolic function of the chronically overloaded right ventricle and contributes to backward venous flow and systemic congestion. These results call for more attention to RA function in the management of patients with PH. NEW & NOTEWORTHY There is growing awareness of the importance of the right atrial (RA)-right ventricular (RV) axis in pulmonary hypertension (PH). Our results uncover alterations in RA phasic function that are related to depressed RV lusitropic function and contribute to backward venous return and systemic congestion in chronic RV overload. Assessment of RA function should be part of the management and follow-up of patients with PH.

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“…tance (E a )], and diastolic stiffness [measured as end-diastolic elastance (E ed )] as previously described by our group (38,43).…”

Section: Introductionmentioning

confidence: 99%

Right ventricular function correlates of right atrial strain in pulmonary hypertension: a combined cardiac magnetic resonance and conductance catheter study

Tello

Dalmer

Vanderpool

et al. 2020

American Journal of Physiology-Heart and Circulatory Physiology

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“…It is a rapid, low-cost exam with an extremely favorable cost/benefit ratio. It may help in the non-invasive assessment of the hemodynamic RV burden in PAH, allowing a more detailed and precise analysis of the patient's condition compared to the common clinical examination [19,20].…”

Section: May Echocardiographic-imaging Represent the Missing Piece?mentioning

confidence: 99%

The Growing Role of Echocardiography in Pulmonary Arterial Hypertension Risk Stratification: The Missing Piece

Miotti

Papa

Manzi

et al. 2021

JCM

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Pulmonary arterial hypertension (PAH) is a rare, progressive disease with a poor prognosis. The pathophysiologic model is mainly characterized by an afterload mismatch in which an increased right ventricle afterload, driven by increased pulmonary vascular resistance (PVR), leads to right heart failure. International guidelines recommend optimization of treatment based on regular risk assessments to achieve or maintain a low-risk status. Current risk scores are based on a multi-modality approach, including demographic, clinical, functional, exercise, laboratory, and hemodynamic parameters, which lack significant echocardiographic parameters. The originality of echocardiography relies on the opportunity to assess in a non-invasive way a physiologically meaningful combination of easy to measure variables tightly related to right ventricle adaptation/maladaptation to increased afterload, the main determinant of a patient’s prognosis. Echo-derived morphological and functional parameters have been investigated in PAH, proving to have prognostic relevance. Different therapeutic strategies proved to have different effects in reducing PVR. An upfront combination of drugs, including a parenteral prostacyclin, has shown to be associated with right heart reverse remodeling in a greater proportion of patients than other treatment strategies as a function of PVR reduction. Adding echocardiographic data to current risk scores would allow better identification of right ventricle (RV) adaptation in PAH patients’ follow-up. This additional information would allow better stratification of the patient, leading to optimized and personalized therapeutic management.

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“…The right heart's dysfunction has been the point of extensive research over recent years. These studies have mostly investigated the patients with congenital heart disease, acquired valvular heart disease, pulmonary hypertension and advanced heart failure [1][2][3][4]. Influence of myocardial infarction on the right ventricle function [5] and perioperative right ventricle condition [6] have been the main focus of research among patients with coronary artery disease (CAD).…”

Section: Introductionmentioning

confidence: 99%

Impaired right ventricular filling in patients with a chronic coronary syndrome

2021

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Aim: The prognostic value of right ventricle (RV) systolic dysfunction is known but the RV diastolic dysfunction (RVDD) is less investigated, thus the purpose of this study was to assess the incidence of RVDD in patients with coronary artery disease (CAD) and to identify factors associated with its presence. Material and methods: We examined 200 patients with stable CAD (153 men). RV diastolic parameters were studied by echocardiography: peak velocity of early (Et) and late (At) RV fill-ing and their ratio, velocities at the tricuspid annulus (et’, a’t, s’t). Patients were divided into 2 groups: with (n=92) and without RVDD (n=108). Results: Old myocardial infarction (MI) (p=0.007), anterior MI (p=0.001), congestive heart failure (p=0.030) and peripheral arterial disease (p=0.030) were more prevalent in patients with RVDD. The end-systolic dimensions were higher (p=0.010), while left ventricular (LV) ejection fraction (EF) (p=0.044) and the mitral E/A ratio (p<0.001) were lower in this group. No significant differences were found between the groups in the coronary artery stenosis. Independent predictors of the RVDD presence were increased age, old MI, hyperlipidemia, moderate chronic heart failure, peripheral arterial disease, and decreased LVEF. Conclusions: The RV diastolic dysfunction is much more common than systolic dysfunction in patients with stable CAD (46% and 7.5%, respectively). The RVDD presence was predominantly associated with an increase in age and LV systolic dysfunction, but not with coronary artery lesions. The predictive value of RVDD requires further research.

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Right heart failure in pulmonary hypertension: Diagnosis and new perspectives on vascular and direct right ventricular treatment

Cited by 48 publications

References 156 publications

Right ventricular function correlates of right atrial strain in pulmonary hypertension: a combined cardiac magnetic resonance and conductance catheter study

Right ventricular function correlates of right atrial strain in pulmonary hypertension: a combined cardiac magnetic resonance and conductance catheter study

The Growing Role of Echocardiography in Pulmonary Arterial Hypertension Risk Stratification: The Missing Piece

Impaired right ventricular filling in patients with a chronic coronary syndrome

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