Right Ventricular Function in Left Ventricular Disease: Pathophysiology and Implications

doi:10.1016/j.hlc.2013.03.072

Heart, Lung and Circulation

Volume 22, Issue 7, July 2013, Pages 507-511

https://doi.org/10.1016/j.hlc.2013.03.072 Get rights and content

The functions of the left and right ventricles are intimately linked. The right ventricle (RV) has transverse muscle fibres in its free wall and also shares oblique fibres in the interventricular septum with the left ventricle (LV). The latter constitute a link between left and right ventricular contractile function such that LV contraction augments RV contraction – a phenomenon called systolic ventricular interaction. When RV afterload is increased (by raised pulmonary artery pressure) overall contractile performance becomes increasingly dependent on this systolic ventricular interaction because the oblique septal fibres are more mechanically efficient than the free wall transverse fibres in conditions of high RV afterload. When LV end diastolic pressure is increased by heart failure due to LV systolic dysfunction, pulmonary artery pressure becomes raised, imposing an increased afterload on the RV. In such patients global LV performance is reduced, consequently systolic ventricular interaction is reduced resulting in a reduction in RV contractile performance even if the RV is not directly involved in the disease process causing LV systolic dysfunction. Furthermore, as the left ventricle becomes progressively more spherical the septal fibres become less oblique, dramatically reducing their mechanical advantage and further impairing RV contractile function. This ultimately leads to clinical right ventricular failure. This in turn typically results in tricuspid regurgitation and a vicious cycle of right ventricular enlargement with further reduction in the oblique nature of the septal fibres. In addition to the systolic interaction of the LV on the RV, when the RV is enlarged and stretches the pericardium, pericardial and right ventricular diastolic pressures may become markedly increased and this can result in constraint to filling of the LV by the pericardium (pericardial constraint) and by the RV via the interventricular septum (diastolic ventricular interaction).

Section snippets

Causes of RV Impairment

RV dysfunction can occur as a consequence of various aetiologies. The RV may be involved as a part of a global disease involving both ventricles such as arrhythmogenic right ventricular cardiomyopathy or dilated cardiomyopathy (DCM). Alternatively the RV can become specifically impaired as a consequence of RV infarction, or right sided valvular disease. However, most commonly, right ventricular failure is a consequence of increased right ventricular afterload in the context of pulmonary

RV Afterload and RV Systolic Dysfunction

The left ventricle is a high pressure pump. Within limits it is able to respond to increased afterload by increasing its contractility [1]. In contrast, beyond foetal life the healthy RV is a pump operating at substantially lower pressures.

The fibre orientation of the RV is key to understanding the response of the RV to increased afterload.

The free wall of the RV comprises transverse fibres. The left ventricle is encircled by oblique fibres [2], (Fig. 1). The interventricular septum consists

The Vicious Cycle of RV Dysfunction

LV systolic dysfunction results ultimately in a globular LV shape with a gradual change in the orientation of the oblique septal fibres to a more transverse configuration. This has adverse consequences for both LV and RV systolic function, (Fig. 3). The combination of pulmonary hypertension and loss of the oblique orientation of the septal fibres frequently leads to progressive RV dilation and the development of clinical RV failure. The RV dilation in turn causes tricuspid regurgitation (TR).

Prognostic Impact of RVSD in LV Disease

Reduced RVEF is a strong prognostic predictor of death or urgent transplantation in HF patients. Ghio et al. studied 379 patients by right heart catheterisation with moderate to severe HF (due to IHD or DCM) and LVEF < 35%, followed up over median time of 17months. Both high mean PAP and low RVEF were found to be independent predictors of survival [13]. The worst survival prognosis was found in patients with combination of high mean PAP and low RVEF.

To date the largest data evaluating the

Diastolic Ventricular Interaction

Whilst the normal LV exerts a favourable systolic interaction on the RV, the enlarged RV with elevated RV diastolic pressure may exert an unfavourable diastolic interaction (diastolic ventricular interaction) on the LV which reduces LV diastolic filling despite an increased LVEDP. Distension of the surrounding pericardium also plays an important role in impeding LV diastolic filling (pericardial constraint). These phenomena have been well described in acute models of pulmonary hypertension [20]

Summary

RV systolic dysfunction frequently coexists with LV systolic dysfunction. Changes in the complex fibre orientation and systolic ventricular interaction can explain this chamber interdependence. RV systolic dysfunction is a potent prognostic marker of outcome in HF patients with LV systolic disease. RV dysfunction is also associated with reduced exercise capacity in this population. The latter can be partly explained by diastolic ventricular interaction which occurs in conditions associated with

Funding

KS is supported by a Medical Research Council grant. SS is supported by a British Heart Foundation grant.

Acknowledgements

We would like to thank our previous collaborators J.V. Tyberg, I. Belenkie and J.J. Atherton who have significantly contributed to the research field of right ventricular function in LV disease.

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Right Ventricular Response to Cardiac Resynchronization Therapy: A Three-Dimensional and Speckle Tracking Echocardiographic Study
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Cardiac resynchronization therapy (CRT) induces left ventricle reverse remodeling; however, its effects on right ventricular (RV) volumes and function were not well described. This study aimed to assess the effects of CRT on RV. Of 112 patients, 63 enrolled with a mean age of 62.77 ± 7.23 years, including 40 males (63.5%). All patients met criteria for CRT implantation and were followed at 3-month and 6-month intervals. Standard 2-dimensional/3-dimensional (3D) echocardiography and speckle-tracking analyses were conducted for assessment of LV and left atrium (LA). RV maximum diameters, tricuspid lateral annular systolic velocity, tricuspid annular plane systolic excursion, fractional area change, RV global (RV 4-chamber strain (RV4CSL), and RV free wall strain (RVFWSL), in addition to 3D echocardiographic assessment of RV, were done before CRT implantation and at follow-up visits. Mean follow-up period was 6.76 ± 1.25 months. A total of 48 patients (76.2%) were LV responders (LVR) whereas the rest were nonresponders (LVNR). Both groups had similar baseline characteristics, risk factors, device implantation, and programming values. Only LVR had significant reduction in RV basal diameter, together with significant improvement of RV systolic performance: systolic velocity, fractional area change, RV4CSL, RVFWSL, and 3D-derived RV volumes and ejection fraction, compared with baseline values. In addition, pulmonary arterial systolic pressure decreased in LVR with reduction of tricuspid regurgitation severity. LV response, percentage change of RV4CSL, LA end-systolic volume index, and LA emptying fraction at 3-month follow-up were the most independent predictors of RV response by multivariate analysis. Reduced left ventricular end-systolic volume >13.5% had 92.3% sensitivity and 81.8% specificity. In conclusion, CRT-induced RV reverse remodeling and improved RV-arterial coupling. These effects were associated with left side response to CRT.
Right Ventricle Function in Patients With Anterior Myocardial Infarction: Are We Sure it Is Not Involved?
2022, Current Problems in Cardiology
Citation Excerpt :
As is well known RV systolic dysfunction being a negative prognostic marker of outcome in patients with LV systolic disease and heart failure. Therefore, all therapeutic interventions for LV systolic disease need to take close consideration of these hemodynamic interactions and the impact on the RV.27 Recently, the right heart function has become a topic of greater interest, in contrast with the LV that has always been the most important clinically.
The right and left ventricle of heart are intimately connected by anatomical and functional links. Hence, acute changes in cardiac geometry and function can modify the performance and physiology of both sides of the heart, influencing each other. After a brief overview of the anatomy and related imaging techniques for the study of right ventricular function, we report a review-on the interesting correlation of acute anterior myocardial infarction and right ventricular function, very often underestimated.
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2D speckle tracking echocardiography (2DSTE) is superior to standard echocardiography in the assessment of subtle right ventricle (RV) systolic dysfunction. In this study we aimed to: 1) test the hypothesis that 2DSTE may unveil subtle RV systolic dysfunction in patients with Fabry disease; 2) investigate whether the physiologic difference between the 3-segment (RV-FWS) and the 6-segment (RV-GLS) RV strain (∆RV strain) is preserved in Fabry patients.
Standard echocardiography and 2DSTE were performed in 49 Fabry patients and 49 age- and sex-matched healthy controls. Fabry patients were divided in two groups according to the presence/absence of left ventricular hypertrophy (LVH+: left ventricular wall thickness > 12 mm, 49% of total Fabry patients). RV systolic function assessed by standard echocardiography was normal in the majority of Fabry patients (92%) while RV-GLS and RV-FWS were impaired in about 40%. RV-GLS and RV-FWS were significantly worse in patients LVH+ vs LVH- and vs controls (RV-GLS: LVH+ vs LVH-: −18.4 ± −4.3% vs −23.8 ± −3.1% p<0.001; LVH+ vs controls: −18.4 ± −4.3% vs −23.9 ± −2.8% p<0.001; RV-FWS: LVH+ vs LVH-: −21.8 ± −5.3% vs −26.7 ± −3.8% p = 0.002, LVH+ vs controls −21.8 ± −5.3% vs −26.8 ± −3.9% p<0.001). No difference was found between LVH- patients and controls in both RV-GLS (p = 0.65) and RV-FWS (p = 0.79). ∆RV strain was similar among the groups.
In Fabry cardiomyopathy impaired RV-GLS and RV-FWS is a common finding, while RV strain is preserved in Fabry patients without overt cardiac involvement. The physiologic difference between RV-FWS and RV-GLS is maintained in Fabry patients, regardless of the presence of cardiomyopathy.
Right Ventricular Global Longitudinal Strain and Outcomes in Heart Failure with Preserved Ejection Fraction
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Right ventricular (RV) strain has emerged as an accurate tool for RV function assessment and is a powerful predictor of survival in patients with heart failure with reduced ejection fraction. However, its prognostic impact in patients with heart failure with preserved ejection fraction (HFpEF) remains unclear. The aim of this study was to compare the prognostic value of RV global longitudinal strain (RVGLS) by two-dimensional speckle-tracking echocardiographic (STE) imaging in patients with HFpEF against conventional RV function parameters.
Patients with HFpEF were prospectively recruited, and 149 of 183 (81%) with analyzable STE RVGLS images constituted the final study population (mean age, 78 ± 9 years; 61% women), compared with 28 control subjects of similar age and sex. All control subjects and 120 patients also underwent cardiac magnetic resonance imaging. Patients were followed up for a primary end point of all-cause mortality and first heart failure hospitalization, and Cox regression analysis was performed.
Mean STE RVGLS was significantly altered in patients with HFpEF compared with control subjects (−21.7 ± 4.9% vs −25.9 ± 4.2%, P < .001). STE RVGLS correlated well with RV ejection fraction by cardiac magnetic resonance (r = −0.617, P < .001). Twenty-eight patients with HFpEF (19%) had impaired STE RVGLS (>−17.5%). During a mean follow-up period of 30 ± 9 months, 91 patients with HFpEF (62%) reached the primary end point. A baseline model was created using independent predictors of the primary end point: New York Heart Association functional class III or IV, hemoglobin level, estimated glomerular filtration rate, and the presence of moderate or severe tricuspid regurgitation. Impaired STE RVGLS provided significant additional prognostic value over this model (χ² to enter = 7.85, P = .005). Impaired tricuspid annular plane systolic excursion and fractional area change, however, did not.
In patients with HFpEF, impaired RVGLS has strong prognostic value. STE RVGLS should be considered for systematic evaluation of RV function to identify patients at high risk for adverse events.
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Copyright © 2013 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Ltd. All rights reserved.

ReviewRight Ventricular Function in Left Ventricular Disease: Pathophysiology and Implications

Section snippets

Causes of RV Impairment

RV Afterload and RV Systolic Dysfunction

The Vicious Cycle of RV Dysfunction

Prognostic Impact of RVSD in LV Disease

Diastolic Ventricular Interaction

Summary

Funding

Acknowledgements

Pediatric Cardiac Surg Ann

Biophys J

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Am Heart J

Comparison of measures of left ventricular contractile performance derived from pressure–volume loops in conscious dogs

Circulation

A silicone rubber mould of the heart

Technol Health Care

The ventricular septum: the lion of right ventricular function, and its impact on right ventricular restoration

Eur J Cardiothorac Surg

Myocardial fiber architecture and left ventricular function

Technol Health Care

Measurement of midwall myocardial dynamics in intact man by radiography of surgically implanted markers

Circulation

Significant left ventricular contribution to right ventricular systolic function

Am J Physiol – Heart Circ Physiol

Review
Right Ventricular Function in Left Ventricular Disease: Pathophysiology and Implications