Assessment of right heart function

Growing recognition of the contribution of right heart function to cardiac output in a variety of pathologic conditions lends a new outlook to cardiac assessment, especially when cardiac output is inadequate for physiologic needs. Signs and symptoms of right heart dysfunction made by physical assessment can be validated by radiologic techniques as well as a newly available bedside method of thermodilution determination of right ventricular ejection fraction and right ventricular end-diastolic and end-systolic volumes. Assessment of right ventricular function can aid clinical decision making when pressure readings obtained by usual hemodynamic monitoring techniques are altered by changes in intrathoracic pressure or ventricular compliance. This article reviews physical assessment of right heart function, signs and symptoms of right heart dysfunction, radiographic evaluations and their limitations and introduces the thermodilution evaluation of right ventricular performance. Clinical examples are presented to illustrate the utility of this new technique along with selected nursing diagnoses and outcome criteria.     

Importance of bedside echocardiography for detection of unsuspected isolated right ventricular infarction as a cause of cardiovascular collapse

Isolated right ventricular infarction is a rare and commonly overlooked condition, because of scarce electrocardiographic changes. We present 2 cases of isolated right ventricular infarction that went unrecognized in the ED. Both patients presented with signs of circulatory collapse, third-degree atrioventricular block, and without prominent ischemic changes in the electrocardiogram. Diagnosis was further obfuscated by the absence of chest pain and atypical clinical presentation with left-hand paresis in one patient and hypothermia in the second. Echocardiography was performed as part of the evaluation of unexplained hypotension. In both cases, it revealed right ventricular dysfunction, which suggested possible acute right ventricular infarction. Diagnosis was confirmed by the finding of subtotal ostial thrombotic occlusions of the right coronary artery in both cases. Echocardiography played a decisive role in the diagnostic procedure, enabling prompt therapeutic intervention and subsequent resolution of shock.     

Pericarditis and Pulmonary Artery Stenosis Due to an Extragonadal Non-seminomatous Germ Cell Tumor: Case Report and Review of the Literature

Background

Chest pain is a common complaint in the Emergency Department that rarely can be attributed to anterior mediastinal masses.

Objectives

We review the differential diagnosis for anterior mediastinal masses and their potential consequences.

Case Report

An unusual case of chest pain in a young male patient is presented that is caused by an anterior mediastinal mass associated with pericarditis and right ventricular outflow obstruction.

Conclusion

Pericarditis and right ventricular outflow obstruction are potential complications of anterior mediastinal non-seminomatous germ cell tumors.     

Permanent Ventricular Pacing Via the Great Cardiac Vein

Two cases of left ventricular pacing via the great cardiac vein are presented. A 64-year-old female with a mechanical prosthetic tricuspid valve and slow atrial fibrillation had a failed attempt at pacing from the middle cardiac vein. In a 58-year-old male with hypertrophic obstructive cardiomyopathy and brodycardia tachycardia svndrome. transvenous permanent pacing could not be achieved via the right ventricle or middle cardiac vein. In both cases, successful pacing via the great cardiac vein was achieved but with an elevated stimulation threshold. These cases illustrate an alternate transvenous route when difficulties occur using standard ventricular pacing sites.     

室间隔缺损合并畸形的外科治疗

本文报告室间隔缺损合并其他心脏畸形92例,占同期行室间隔缺损修补术病例13％。合并畸形包括房间隔缺损、动脉导管未闭、右室流出道狭窄、主动脉辦脱垂或关闭不全、主动脉窦瘤、双腔右心室、室间隔膜部瘤、先天性二尖辦狭窄或关闭不全。作者论述了各种复合畸形的临床特征,手术方法和术中应注意的问题。     

Left ventricular apical diastolic collapse: an unusual echocardiographic marker of postoperative cardiac tamponade.

A 37-year-old woman was evaluated for signs and symptoms of cardiac tamponade 11 days after mitral valve replacement and tricuspid valve repair. The transthoracic echocardiogram showed a large, compartmentalized pericardial effusion that resulted in left ventricular apical diastolic collapse. Also noted were right ventricular posterior wall diastolic collapse and hemodynamic findings consistent with cardiac tamponade. This case highlights the atypical echocardiographic findings in patients with pericardial effusions after cardiac surgery.     

Right Ventricular Outflow Tract Tachycardia as a Result of Blunt Chest Trauma

Two patients presented with monomorphic ventricular tachycardia after blunt chest trauma. In both cases, the arrhythmia had a left bundle branch block, inferior axis morphology comparable to that seen with idiopathic ventricular tachycardia originating from the right ventricular outflow tract (RVOT). In one patient, the arrhythmia persisted and required catheter ablation. A history of cardiac trauma should be considered in patients presenting with RVOT tachycardia.     

Cardiac amyloidosis

In our experience, QS pattern of poor R wave progression and atrio-ventricular block of varying degrees on electrocardiogram, cardiomegaly with pleural effusion on chest X-ray film, left ventricular wall thickening, pericardial effusion and findings suggesting left ventricular diastolic dysfunction on echocardiogram and increased right ventricular end-diastolic pressure in cardiac catheterization were frequently observed in patients with cardiac amyloidosis. Though none of these findings are specific, we should suspect cardiac amyloidosis as a possibility when some of these signs are observed in patients with chronic cardiac failure of unknown etiology. Left ventricular mass obtained from echocardiography could be useful predictive parameter of prognosis in patients with cardiac amyloidosis.     

Unusual Features of Right and Left Idiopathic Ventricular Tachycardia Aholished hy Radiofrequency Catheter Ablation

Two unusual cases are presented with idiopathic right and left ventricular tachycardia(IVT) with intriguing clinical and electrophysiological characteristics. The first patient with a sustained IVT of right ventricular outflow tract origin, and an electrophysiological mechanism suggesting reentry, had been resuscitated from cardiac arrest. The second patient had an IVT with a left bundle branch block morphology, which originated from the basal-septal region of the left ventricle(left ventricular outflow tract tachycardia). Both patients were cured with radiofrequency catheter ablation, guided by endocardial activation sequence and pace mapping.     

Clinico-functional characteristics of pulmonary heart disease developing at high altitude as a result of chronic bronchitis

It was shown that the high-altitude conditions of the Pamirs and Tien Shan (2800-3600 m above the sea-level) modified the clinicofunctional signs and a course of the cor pulmonale (CP) in chronic bronchitis. CP was detected in the examined patients with chronic bronchitis. As compared to the conditions of foothills (760 m) CP in mountain-dwellers was more noticeable in terms of the signs of pulmonary arterial hypertension, right ventricular hypertrophy developed in them 5 years earlier. The first obvious signs of cardiac decompensation developed in the presence of moderate (noticeable at the foothills) right ventricular hypertrophy and were often (51.5% of the patients against 21.6% under the foothills conditions) accompanied by disturbance of cardiac rhythm and conduction.     

右室流入道起搏治疗缓慢性心律失常44例临床研究

目的采用右室流入道和传统的右室心尖部起搏两种不同的方法治疗缓慢性心律失常,观察起搏参数、并发症、心电图QRS时限和心功能的变化。方法随机将86例患者分为右室流入道起搏组44例,右室心尖部起搏组42例,分别观察两组起搏器植入时、起搏3和6个月时的起搏参数、并发症、心电图QRS时限和心功能的变化。结果两组不同时期起搏参数、并发症比较,差异无统计学意义;而右室流入道起搏组心电图QRS时限明显短于右室心尖部,心功能改善也显著优于右室心尖部,差异有统计学意义,且心功能改善随起搏时间延长呈逐步好转趋势,而心电图QRS时限不同时期时限较固定。结论采用右室流入道起搏治疗,其心功能改善明显优于传统的右室心尖部起搏,值得在临床上推广。     

Cardiac Sarcoidosis Masquerading as Right Ventricular Dysplasia

Patients with cardiac sarcoidosis may present with clinical and morphological features similar to arrhythmogenic right ventricular dysplasia (ARVD) or cardiomyopathy (ARVC). Three cases of cardiac sarcoidosis are presented that clinically mimicked ARVD or ARVC until a pathology diagnosis of sarcoidosis was made at biopsy or autopsy. A diagnostic distinction, while often difficult to make, is important since treatment with corticosteroids may benefit those with sarcoidosis but is not expected to be useful in cases with ARVD or ARVC. (PACE 2003; 26[Pt. I]:1498–1503)     

法乐四联症根治术96例临床分析

目的 :总结 96例法乐四联症根治手术的临床经验。方法 :术中以间断褥式缝合绦纶补片修补室间隔缺损 (VSD) ,以经戊二醛处理的牛心包补片进行流出道成形增宽 ,其中 3 7例进行跨肺动脉瓣环成形。结果 :术后出现低心排血量综合征 9例 ,心律失常 7例 ;出血及心包填塞 4例 ;肺水肿 4例 ;肾功能不全 3例 ;胸腔积液 3例。术后死亡 3例 ,死亡原因、低心排 2例 ,室性心律失常 1例 ,死亡率 3 12 %。结论 :术中满意的室缺修补及流出道疏通成形 ,加上合理的围术期处理是法乐四联症根治术成功的关键。     

Echocardiographic evaluation of right ventricular systolic functions in pure mitral stenosis

Detailed echocardiographic evaluation of right ventricular muscle thickness and systolic functions was performed in twenty two cases of isolated rheumatic mitral stenosis without clinical signs of systemic venous congestion, tricuspid regurgitation or atrial fibrillation. Twenty two age and sex matched normal persons formed the control group. Right ventricular thickness was significantly increased in the patients with mitral stenosis. End-diastolic and end-systolic long axis measurements and areas were significantly increased and fractional shortening of these parameters was significantly reduced in the patient group. Our results show that right ventricular systolic functions are significantly impaired even in absence of clinical signs of systemic venous congestion. This impairment of systolic function did not correlate with pulmonary flow acceleration time. Myocardial involvement in rheumatic process could be one possibility. Systolic movement of the Tricuspid annulus and right ventricular mid cavity short axis dimension were not sensitive in detecting right ventricular systolic dysfunction.     

右心室功能的MRI初步研究

目的：初步评价采用相位对比法MRI测量右心室的搏出量和心输出量的准确性及应用价值。材料与方法：选取无心肺疾病的正常健康人21例,先天性心脏病患者3例作为研究对象,应用Philips 1.5T MR成像仪,测量了肺动脉的血流速度和瞬时流量,同时记录各研究对象的心率,然后计算出右心室的搏出量和心输出量。结果：正常健康人右心室的搏出量和心输出量分别为73.63±6.58ml和5.41±0.73L,3例先天性心脏病中,室间隔缺损患者右心室的搏出量和心输出量为87.2ml和9.16L,房间隔缺损患者右心室的搏出量和心输出量为159.0ml和8.75L,动脉导管未闭患者右心室的搏出量和心输出量为46.9ml和4.92L。结论：MRI不仅可以清楚显示心脏大血管的解剖结构,而且能够通过准确测量肺动脉血流速度和血流量,计算出右心室的搏出量和心输出量,进而达到初步评价右心室功能的目的。     

The deleterious consequences of right ventricular apical pacing: time to seek alternate site pacing

BACKGROUND: The purpose of this article is to critically review the data accumulated to date from studies evaluating the hemodynamic and clinical effects of right ventricular apical pacing during conventional permanent cardiac pacing. The data from studies comparing the effects of right ventricular apical pacing and alternate site ventricular pacing are also reviewed. METHODS: We conducted a MEDLINE and journal search of English-language reports published in the last decade and searched relevant papers. RESULTS: Although intraventricular conduction delay in the form of left bundle branch block (LBBB) has traditionally been viewed as an electrophysiologic abnormality, it has now become abundantly clear that it has profound hemodynamic effects due to ventricular dyssynchrony, especially in patients with heart failure. These deleterious effects can be significantly ameliorated by cardiac resynchronization therapy effected by biventricular or left ventricular pacing. However, not only is spontaneous LBBB harmful, but the iatrogenic variety produced by right ventricular apical pacing in patients with permanent pacemakers may be equally deleterious. In this review new evidence from recent studies is presented, which strongly suggests a harmful effect of our long-standing practice of producing an iatrogenic LBBB by conventional right ventricular apical pacing in patients receiving permanent pacemakers. This emerging strong new evidence about the adverse hemodynamic and clinical effects of right ventricular apical pacing would dictate a reassessment of our traditional approach to permanent cardiac pacing and direct our attention to alternate sites of pacing, such as the left ventricle and/or the right ventricular outflow tract or septum, if not for all patients, at least for those with left ventricular dysfunction. Indeed, current convincing data on alternate site ventricular pacing are encouraging and this approach should be actively pursued and further investigated in future studies. CONCLUSIONS: Not only is spontaneous permanent LBBB harmful to our patients, but the iatrogenic variety produced by right ventricular apical pacing during conventional permanent pacing may also be deleterious to some patients. The compelling evidence presented herein cannot be ignored; it may dictate a change of attitude toward right ventricular apical pacing directing our attention to alternate sites of ventricular pacing and avoidance of the right ventricular apex.     

Arrhythmogenic right ventricular dysplasia masquerading as an abdominal episode

A 19-year-old woman presented with abdominal pain. Aside from epigastric tenderness, the patient’s physical examination was unremarkable. She developed ventricular tachycardia with left bundle branch block morphology shortly after admission. Echocardiography revealed a thin, enlarged, and hypokinetic right ventricle. Electron beam computed tomography demonstrated hypodense areas in the right ventricular free wall suggestive of fatty infiltration, which suggested arrhythmogenic right ventricular dysplasia. The diagnosis was confirmed with the use of cardiac magnetic resonance imaging. The patient received an implantable card ioverter-defibrillator. This case illustrates a noncardiac presentation of a rare yet treatable cardiac condition.     

Stable tachycardia as a cause of heart failure

The authors described a patient in whom the right vagus had been cut during removal of hormonally inactive chemodectoma in the bifurcation of the external and internal carotid arteries. Stable sinus and then atrial tachycardia (140-180 strokes per min.) developed on the operating table. Congestive cardiac insufficiency developed in 3 yrs. Treatment with diuretics cardiac glycosides was ineffective. Clinical and x-ray signs of cardiac insufficiency disappeared after atrial tachycardia was converted into atrial fibrillation with ventricular contractions up to 80 per min. A conclusion has been made that stable tachycardia causes the development of cardiac insufficiency.     

Idiopathic constriction of the fetal ductus arteriosus.

Constriction of the ductus arteriosus in the fetus is well studied, but mostly secondary to maternal exposure to indomethacin or other non-steroidal anti-inflammatory medications, or structural cardiac lesions. We present a case of a fetus presenting with right ventricular hypertrophy secondary to an S-shaped ductus arteriosus with distal constriction diagnosed by pulsed Doppler imaging. A review of the recent English literature of similar cases is presented.     

Differential diagnosis of intracavitary tumors obstructing the right ventricular outflow tract.

Three cases of right ventricular outflow tract obstruction caused by 3 distinct tumors-myxoma, sarcoma, and presumed metastatic tumor-diagnosed by transthoracic and transesophageal echocardiography are presented. The differences among these 3 types of tumors with similar clinical and echocardiographic findings are highlighted, and a review of the pertinent literature is discussed. By applying the approximate frequencies of cardiac tumors categorized by type and site, statistically, an intracavitary right ventricular outflow tract tumor is 70 to 140 times more likely to be malignant than benign; furthermore, if it is a primary cardiac tumor, it is approximately 2 times more likely to be a sarcoma than a myxoma.