This document was developed by the American College of Cardiology Foundation (ACCF) Task Force on Clinical Expert Consensus Documents (ECDs) and cosponsored by the American College of Radiology (ACR), American Heart Association (AHA), North American Society for Cardiovascular Imaging (NASCI), and

ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents

http://www.plicnihypertenze.cz/proodborniky/novinky/5-svetova-konference-ph/rigt-heart-adoption-to-pah.pdf

Right Heart Adaptation to Pulmonary Arterial Hypertension: Physiology and Pathobiology

Expert Consensus DocumentACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents

Heart failure and preserved ejection fraction patients (n ¼ 96) and controls (n ¼ 46) underwent right heart catheteriza- tion, echocardiographic assessment, and follow-up. Right and left heart filling pressures, pulmonary artery (PA) pressures, and right-sided chamber dimensions were higher in HFpEF compared with controls, while left ventricular size and EF were similar. Right ventricular dysfunction (defined by RV fractional area change, FAC ,35%) was present in 33% of HFpEF patients and was associated with more severe symptoms and greater comorbidity burden. Right ventricular function was impaired in HFpEF compared with controls using both load-dependent (FAC: 40+ 10 vs. 53+ 7%, P , 0.0001) and load-independent indices (FAC adjusted to PA pressure, P ¼ 0.003), with enhanced afterload-sensitivity compared with controls (steeper FAC vs. PA pressure relationship). In addition to haemodynamic load, RVD in HFpEF was asso- ciated with male sex, atrial fibrillation, coronary disease, and greater ventricular interdependence. Over a median follow-up of 529 days (IQR: 143-1066), 31% of HFpEF patients died. In Cox analysis, RVD was the strongest predictor of death (HR: 2.4, 95% CI: 1.6-2.6; P , 0.0001). Conclusion Right heart dysfunction is common in HFpEF and is caused by both RV contractile impairment and afterload mismatch from pulmonary hypertension. Right ventricular dysfunction in HFpEF develops with increasing PA pressures, atrial fibrillation, male sex, and left ventricular dysfunction, and may represent a novel therapeutic target.

Right heart dysfunction in heart failure with preserved ejection fraction

… And I ask, as the lungs are so close at hand, and in continual motion, and the vessel that supplies them is of such dimensions, what is the use or meaning of this pulse of the right ventricle? And why was nature reduced to the necessity of adding another ventricle for the sole purpose of nourishing the lungs? — —William Harvey, Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus, 1628 

There is still no answer to William Harvey’s rhetorical question. He included the right ventricle (RV), its “pulse,” the large pulmonary arteries (PAs), and the lungs in the same sentence, emphasizing the concept of a “unit.” Although Harvey realized the importance of the RV and its interactions with the pulmonary circulation, 4 centuries later, the RV is largely understudied. At the same time, there has been significant progress in our understanding of the pathology of pulmonary vascular disease and, over the past few years, an explosion of clinical therapeutic trials for PA hypertension (PAH).1 This unbalanced approach has generated a number of problems and controversies. For example, it is now becoming apparent that even if experimental therapies improve or reverse PAH pathology, this does not necessarily lead to clinical improvement and prolonged survival unless accompanied by a parallel improvement in RV function. The degree of pulmonary hypertension (ie, PA pressure [PAP]) does not strongly correlate with symptoms or survival, whereas RV mass and size and right atrial pressure reflect functional status and are strong predictors of survival.2 The 6-minute walk test, used as the primary end point in most PAH clinical trials, correlates better with RV function (ie, cardiac output) than with the degree of pulmonary pressure elevation. However, this test is being heavily criticized because of multiple inherent problems and the fact that it does …

Comprehensive Invasive and Noninvasive Approach to the Right Ventricle–Pulmonary Circulation Unit State of the Art and Clinical and Research Implications

Background— The aims of this study were to validate MRI-derived right ventricular (RV) pressure-volume loops for assessment of RV myocardial contractility and then to apply this technique in patients with chronic RV pressure overload for assessment of myocardial contractility, ventricular pump function, and VA coupling. Methods and Results— Flow-directed catheters were guided under MR fluoroscopy (1.5 T) into the RV for invasive pressure measurements. Simultaneously, ventricular volumes and myocardial mass were assessed from cine MRI. From sampled data, RV pressure-volume loops were constructed, and maximal ventricular elastance indexed to myocardial mass (Emax_i) was derived by use of a single-beat estimation method. This MRI method was first validated in vivo (6 swine), with conductance techniques used as reference. Bland-Altman test showed good agreement between methods (Emax_i=5.1±0.5 versus 5.8±0.7 mm Hg · mL−1 · 100 g−1, respectively; P=0.08). Subsequently, the MRI method was applied in 12 subjects:...

Magnetic resonance imaging analysis of right ventricular pressure-volume loops - In vivo validation and clinical application in patients with pulmonary hypertension

Eckard Fleck

Papers

Magnetic resonance imaging analysis of right ventricular pressure-volume loops - In vivo validation and clinical application in patients with pulmonary hypertension