Right ventricular dysfunction in chronic dilated cardiomyopathy and heart failure

In patients with advanced heart failure, the main focus has traditionally been placed on the functional assessment of the left ventricle. Therefore, the current body of literature examining the right ventricle and its influence on the pathophysiological processes in heart failure has been limited. Methods currently employed to assess the size and function of the right ventricle include: high frequency thermodilution, contrast ventriculography, radionuclide ventriculography, echocardiography, and magnetic resonance imaging; however, none of these techniques has proven to be a 'gold standard' for the assessment of right ventricular function. Nevertheless, when these methods are employed, right ventricular dysfunction has been shown to be a powerful predictor of reduced exercise capacity and survival. This relationship holds true for patients with heart failure secondary to either ischemic or non-ischemic dilated cardiomyopathy.     

Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure

Objectives. We sought to study the relationship between survival and right ventricular ejection fraction (RVEF) in a subgroup of patients with moderate congestive heart failure (CHF).Background. It has been demonstrated that RVEF is an independent predictor of survival in patients with advanced CHF.Methods. Cardiopulmonary exercise testing and radionuclide angiography (to determine right and left ventricular ejection fraction) were prospectively performed in 205 consecutive patients with moderate CHF (140 patients in New York Heart Association [NYHA] class II, 65 in class III).Results. Left ventricular ejection fraction was 29.3% ± 10.1%, RVEF was 37.5% ± 14.6% and peak oxygen consumption (VO₂) was 16.2 ± 5.4 ml/min/kg (60.2% ± 19% of maximal predicted VO₂). After a median follow-up period of 755 days, there were 44 cardiac-related deaths, 3 deaths from noncardiac causes and 15 transplantations of whom 2 were urgent; 1 patient was lost to follow-up. Multivariate analysis showed that three variables—NYHA classification, percent of maximal predicted VO₂and RVEF—were independent predictors of both survival and event-free cardiac survival. Left ventricular ejection fraction and peak VO₂normalized to body weight had no predictive value. The event-free survival rates from cardiovascular mortality and urgent transplantation at 1 year were 80%, 90% and 95% in patients with an RVEF <25%, with a RVEF ≥25% and <35% and with a RVEF ≥35%, respectively. At 2 years, survival rates were 59%, 77% and 93% in the same subgroups, respectively.Conclusions. In addition to the NYHA classification and to the percent of maximal predicted VO₂, RVEF is an independent predictor of survival in patients with moderate CHF.     

Right ventricular dilated cardiomyopathy

Fourteen patients with predominantly right sided dilated cardiomyopathy were studied, of whom five died suddenly. The condition is characterised by male preponderance, syncope, ventricular tachycardia, which typically has a left bundle branch block pattern on the surface electrocardiogram, and right heart failure. The diagnosis should be considered in patients presenting with otherwise unexplained ventricular tachycardia or syncope; the diagnosis may be readily missed because of the nonspecific nature or absence of signs.     

Right ventricular dysfunction as an independent predictor of short- and long-term mortality in patients with heart failure

BACKGROUND: The prognostic importance of right ventricular (RV) dysfunction in heart failure (HF) has been suggested in patients with severe systolic heart failure. Tricuspid annular plane systolic excursion (TAPSE) is a simple echocardiographic measure of RV ejection fraction, but may be affected by co-existing chronic obstructive pulmonary disease (COPD). AIMS: To examine the prognostic information from TAPSE adjusted for the potential confounding effects of co-existing cardiovascular and COPD in a large series of patients admitted for new onset or worsening HF. METHODS AND RESULTS: Eight hundred and seventeen patients screened for participation in a large clinical trial by trans-thoracic echocardiography, including measurement of TAPSE, were followed for a median of 4.1 years (maximum 5.5 years). Decreased TAPSE as well as presence of COPD were independently associated with adverse short- and long-term survival, hazard ratio was 0.74 (p=0.004) for every doubling of TAPSE; and 2.4 (p<0.0001) for the presence of COPD. CONCLUSION: Decreased RV systolic function as estimated by TAPSE is associated with increased mortality in patients admitted for HF, and is independent of other risk factors in HF including left ventricular function. The co-existence of COPD is also associated with an adverse prognosis independent of the RV systolic function.     

Initial white blood cell count is an independent risk factor for survival in patients with dilated cardiomyopathy

Background

The impact of white blood cell count (WBCc) on the outcome of patients with non-ischemic left ventricular (LV) dysfunction is unknown. In the present study we investigated the influence of WBCc on mortality and cardiac inflammation in patients with reduced LV systolic function in the absence of ischemic or valvular etiology.

Methods and results

We included 381 patients with reduced left ventricular (LV) ejection fraction (LVEF ≤ 45%) quantified by two-dimensional echocardiography. Coronary artery disease and valvular diseases were excluded by angiography and echo, respectively, in all patients. WBCc was quantified routinely upon first hospital admission. In 291 patients, endomyocardial biopsies from the right ventricle were performed upon first hospital admission for assessment of cardiac inflammation. Follow-up was up to 5.5 years (median 2.93 [1.7;4.0]). Information on vital status of patients was obtained from official resident data files. WBCc > 11 Gpt/l was associated with significantly increased mortality in patients with severe LV dilation (end-diastolic diameter (LVEDD) > 70 mm quantified by echocardiography) in comparison to patients showing WBCc ≤ 11 Gpt/l (41.7% vs 13.6%, p = 0.02). Multivariable Cox regression analysis showed that WBCc predicts mortality independently of other cardiovascular risk factors and LVEF (hazard ratio 1.14; p = 0.04). Doses of heart failure medication did not differ significantly in patients with LVEDD > 70 mm and WBCc > 11 Gpt/l when compared to LVEDD > 70 mm and WBCc ≤ 11 Gpt/l (percent of maximum doses: ß-blockers p = 0.51, ACE inhibitors p = 0.56, AT1 antagonists p = 0.77, aldosterone antagonists p = 0.35). WBCc including its subpopulations (monocytes, lymphocytes and granulocytes) did not show a significant correlation with cardiac amounts of CD3⁺-lymphocytes (r = 0.02, p = 0.78) or CD68⁺-macrophages (r = 1.0, p = 0.09) (n = 291).

Conclusion

WBCc at first hospital admission predicts long term-mortality in patients with dilated cardiomyopathy independently of cardiovascular risk factors.     

Right ventricular dilated cardiomyopathy.

Fourteen patients with predominantly right sided dilated cardiomyopathy were studied, of whom five died suddenly. The condition is characterised by male preponderance, syncope, ventricular tachycardia, which typically has a left bundle branch block pattern on the surface electrocardiogram, and right heart failure. The diagnosis should be considered in patients presenting with otherwise unexplained ventricular tachycardia or syncope; the diagnosis may be readily missed because of the nonspecific nature or absence of signs.     

Right ventricular function in dilated cardiomyopathy

The right ventricular (RV) function was comprehensively examined in 18 patients with dilated cardiomyopathy (DCMP) and compared with RV function in 10 controls. In most cases of DCMP, the RV function is affected simultaneously with a disturbance of the left ventricular (LV) function. However, the degree of its affection is usually less pronounced and, with less severe LV dysfunction, the right ventricle can work even normally. There can be substantial individual differences in the degree of affection of the right ventricle in DCMP. However, severe LV dysfunction is invariably associated with a marked involvement of the right ventricle. A disturbance of the RV function results (besides the influence of the decreased LV function) from both a decrease in its own contractility and a decrease in RV compliance. There exist significant relations between the RV systolic and diastolic function. The degree of RV disturbance in DCMP both of the systolic and diastolic function) can be approximately estimated from the level of diastolic pressure.     

Dobutamine-induced hypotension is an independent predictor for mortality in patients with left ventricular dysfunction following myocardial infarction

Dobutamine echocardiography was performed on 297 patients after acute myocardial infarction to assess the prognostic value of dobutamine-induced hypotension in patients with left ventricular dysfunction. Patients were divided into two groups according to ejection fraction (group I, ejection fraction <0.45, n = 123; group II, ejection fraction > or =0.45, n = 174) and were followed for 20+/-8 months. Hypotension was defined as a decrease in systolic blood pressure > or =20 mm Hg, compared with baseline values. The incidence of hypotension was similar in groups I and II (23.6% vs. 18.4%, P = 0.28), and the hypotension was not related to positive dobutamine echocardiography. Univariate analysis showed that the development of hypotension was associated with a higher incidence of cardiac death in group I but not in group II. Multivariate analysis showed that dobutamine-induced hypotension was an independent predictor only for cardiac death in group I and was not related to any other cardiac events in either group. In conclusion, the development of hypotension during dobutamine stress can identify a subgroup with poor ventricular functional reserve and at high risk for cardiac death among patients complicated with left ventricular dysfunction.     

Anaemia is an independent predictor of mortality in patients with left ventricular systolic dysfunction following acute myocardial infarction

BACKGROUND: In patients with chronic heart failure (HF), mortality is inversely related to haemoglobin (hgb) concentration. We investigated the prognostic importance of anaemia in patients with acute myocardial infarction (AMI) and left ventricular systolic dysfunction (LVSD) with and without HF. METHODS AND RESULTS: We studied 1731 patients with AMI and left ventricular ejection fraction 相似文献   

Right ventricular filling in dilated cardiomyopathy.

PURPOSE--To assess right ventricular filling in dilated cardiomyopathy. PATIENTS--32 patients with dilated cardiomyopathy and 24 healthy controls. METHODS--Stroke distances were measured by pulsed Doppler echocardiography at left ventricular outflow and left and right ventricular inflow. The inflow tract dimensions of both ventricles and the outflow tract dimension of the left ventricle were measured from two dimensional images. Right and left sided atrioventricular (AV) ring excursions were measured by M mode echocardiography at the tricuspid and mitral rings. Stroke volume was derived as stroke distance multiplied by left ventricular outflow tract area. Total stroke distances were calculated as the sum of AV valve Doppler stroke distances and ring excursion. The effective orifice areas of the two AV valves were thus defined as stroke volumes divided by total stroke distance. RESULTS--Total tricuspid stroke distance was normally less than mitral (6.0 (1.7) v 7.6 (1.7) cm, P < 0.05), implying that effective orifice area of the tricuspid valve was consistently greater (6.6 (1.6) v 4.5 (0.8) cm2, P < 0.01). Total tricuspid ring excursion was normally more than mitral (2.30 (0.30) v 1.62 (0.22) cm, P < 0.01). Total tricuspid stroke distance in dilated cardiomyopathy was also less than mitral (7.8 (2.4) v 9.7 (2.8) cm, P < 0.05). Tricuspid stroke distance was significantly increased in patients with dilated cardiomyopathy compared with that in healthy controls (P < 0.05 v controls), though stroke volume was much smaller (26 (10) v 63 (11) ml, P < 0.01) so that tricuspid effective orifice area was reduced to less than half normal (2.7 (1.2) cm2, P < 0.01). Total tricuspid ring long axis excursion was more than mitral (1.37 (0.6) v 0.74 (0.21) cm, P < 0.01). Right ventricular end diastolic inflow dimension was increased compared with that in healthy controls (3.9 (0.7) v 2.8 (0.5) cm, P < 0.01), correlating inversely with tricuspid effective orifice area (r = -0.71, P < 0.01). Total tricuspid ring excursion was bimodally distributed as a low amplitude group (less than 1.6 cm, n = 23) and a high amplitude group (more than 1.6 cm, n = 9), in which the interval P2 to onset of tricuspid flow was much longer (100 (35) v 50 (14) ms, P < 0.01). CONCLUSIONS--Enlargement of the right ventricular inflow tract in dilated cardiomyopathy, especially to more than 5 cm, is accompanied by a progressive decrease in effective tricuspid orifice area, sometimes to less than 1 cm2 and increased inflow velocities. Right ventricular relaxation was incoordinate in 28% of the patients studied. These disturbances of right ventricular filling are likely to compromise overall cardiac function independently of left ventricular disease.     

Right ventricular pacing is an independent predictor for ventricular tachycardia/ventricular fibrillation occurrence and heart failure events in patients with an implantable cardioverter-defibrillator

Aims: There is increasing evidence that right ventricular (RV) pacingmay have detrimental effects by increasing morbidity and mortalityfor heart failure in implantable cardioverter–defibrillator(ICD) patients. In this study we prospectively tested the hypothesisthat cumulative RV pacing increases ventricular tachycardia/ventricularfibrillation (VT/VF) occurrence (primary endpoint) and hospitalizationand mortality for heart failure (secondary endpoint) in a predominantlysecondary prophylactic ICD patient population. Methods and results: Two hundred and fifty patients were divided into two groupsaccording to the median of cumulative RV pacing (2 vs. >2%)and prospectively followed-up for occurrence of primary andsecondary endpoints for 18 ± 4 months. Established predictorsfor VT/VF occurrence and heart failure events such as age, leftventricular ejection fraction (EF), QRS duration, history ofatrial fibrillation, and NT-proBNP were collected at enrolment.Multivariate Cox regression analysis revealed that cumulativeRV pacing > 2% and EF < 40% were independent predictorsfor VT/VF occurrence and heart failure events. Kaplan–Meieranalysis showed that patients with >2% cumulative RV pacingmore frequently suffered from VT/VF occurrence and heart failurehospitalization. Conclusion: Cumulative RV pacing > 2% and EF < 40% are independentpredictors for VT/VF occurrence and mortality and hospitalizationfor heart failure in predominantly secondary prophylactic ICDpatients. Our data show that algorithms capable of reducingcumulative RV pacing should be used more frequently in clinicalpractice.     

Sustained left ventricular diastolic dysfunction after exercise in patients with dilated cardiomyopathy

Objective—To investigate the recovery process of exercise induced diastolic dysfunction in heart failure, using Doppler echocardiographic techniques.
Design and patients—Transmitral flow velocity profiles and standard non-invasive haemodynamic indices were obtained serially over seven days after symptom limited bicycle exercise tests in 18 patients with dilated cardiomyopathy and eight normal subjects. In three patients with cardiomyopathy we also measured the pulmonary capillary wedge pressure for 24 hours after exercise.
Results—The intensity of exercise, as assessed by respiratory gas analysis, was lower in patients with dilated cardiomyopathy than in normal subjects. Despite the higher exercise level, all haemodynamic variables returned to baseline within one hour after exercise in normal subjects. In contrast, patients with dilated cardiomyopathy showed a sustained decrease in the peak early diastolic filling velocity and a sustained increase in the deceleration time of early filling for 24 hours or more after exercise. Because other haemodynamic variables recovered within one hour after exercise even in patients with dilated cardiomyopathy, the postexercise changes in ventricular filling were not explained by changes in loading conditions.
Conclusions—Exercise induced diastolic left ventricular dysfunction of the failing heart persists for 24 hours or more after exercise. The efficacy of exercise training on a daily basis in dilated cardiomyopathy requires further evaluation.

Keywords: exercise;  chronic heart failure;  mitral flow velocity;  diastolic stunning     

Right ventricular dilated cardiomyopathy associated with primary biliary cirrhosis

A case of right ventricular dilated cardiomyopathy associatedwith primary biliary cirrhosis is described. The patient wasa middle aged woman, who initially complained of fatigue anditching. The diagnosis of primary biliary cirrhosis was madebased on clinical, biochemical and histological evidence ofthe disease. Seven years later severe right-sided heart failuredeveloped. The diagnosis of right ventricular dilated cardiomyopathywas made based on echocardiographic and angio graphic evidenceof a globally dilated and poorly contracting right ventricle.Left ventricular function was within normal limits. Autoimmuneserology screening at this time revealed the presence of organ-speccardiac antibody (titre 1/20) and of antinuclear antibody (titre1/80) by indirect immunofluorescence. There were no findingsof mitochondrial antibody or other non-organ specific or organ-specificantibodies. Overall, this assessment demonstrates autoimmunityin both hepatic and heart muscle disease in a patient with primarybiliary cirrhosis and right ventricular dilated cardiomyopathy.     

T-wave axis deviation as an independent predictor of mortality in chronic Chagas' disease

The T-wave axis shift has been reported to represent a general marker of ventricular repolarization abnormalities and a potential indicator of increased risk for cardiovascular mortality. We assessed the prognostic importance of the T-wave axis deviation for mortality rate in patients with chronic Chagas' disease. In a long-term follow-up prospective study, 738 adult outpatients in the chronic phase of Chagas' disease were enrolled. The frontal plane T-wave axis was estimated from 12-lead electrocardiograms obtained on admission and categorized as normal (15 degrees to 75 degrees ), borderline (75 degrees to 105 degrees or 15 degrees to -15 degrees ), and abnormal (>105 degrees or < -15 degrees ). Clinical and radiologic data, 2-dimensional echocardiographic data, and other electrocardiographic data were also recorded. Primary end points were all-cause, those related to Chagas' disease, and sudden cardiac deaths. Statistical analyses included Kaplan-Meier estimation of survival curves and multivariate Cox's proportional hazards models. During a follow-up of 58 +/- 39 months, 62 patients died, 54 from causes related to Chagas' disease and 40 due to sudden cardiac death. Kaplan-Meier survival curves showed that the 3 categories of T axis had significantly different prognoses. Multivariate Cox's survival analysis demonstrated that an abnormal T axis increases the risk of death threefold and sudden death nearly sixfold after adjustment for other covariates, including left ventricular systolic function and other electrocardiographic abnormalities. Borderline T-wave axis also indicated a worse prognosis, particularly in the subgroup of patients with abnormal baseline electrocardiograms. These results indicate that T-wave axis deviation is an easily quantified, strong, and independent mortality risk predictor in patients with chronic Chagas' disease.     

Right ventricular dysfunction,late gadolinium enhancement,and female gender predict poor outcome in patients with dilated cardiomyopathy

Aims

Dilated cardiomyopathy (DCM) shows a variable disease course and is associated with significant morbidity and mortality. So far, left ventricular function (LVF) is the major determinant for risk stratification. However, since it has shown to be a poor guide to individual outcome, we studied the prognostic value of cardiovascular magnetic resonance imaging (CMR) parameters, late gadolinium enhancement (LGE) and epicardial adipose tissue (EAT).

Methods and results

140 patients with DCM underwent late gadolinium enhancement (LGE) CMR. During a median follow-up of 3 years, 22 patients (16%) died and another 51 (36%) were hospitalized due to congestive heart failure (CHF). Female gender and right ventricular ejection fraction (RV-EF) below the median of 38% were independent predictors of all-cause mortality in multivariable analysis. In patients who were hospitalized due to CHF, RV-EF below the median of 38% was the only independent predictor in multivariable analysis. When patients where further stratified according to systolic LV-EF, the prognostic value of RV-EF to predict mortality and cardiac morbidity remained unchanged. Looking at DCM patients who died during follow-up compared to those who were hospitalized due to CHF, the former presented with a higher prevalence of LGE as well as reduced indexed EAT.

Conclusion

Female gender, RV-EF and the presence of LGE are of prognostic importance in patients with DCM. Therefore, the present study underlines the role of CMR as an important tool for risk stratification in patients with DCM.     

Left ventricular enlargement is common in relatives of patients with dilated cardiomyopathy

Idiopathic dilated cardiomyopathy is characterized by dilation and impaired contractility of one or both ventricles. Long-term prognosis is poor. Early diagnosis has the potential for substantial reduction of morbidity and mortality. Recent studies, based on echocardiographic assessment of relatives of the patients have shown that familial dilated cardiomyopathy is relatively common. The authors studied 215 relatives (mean age, 27 years; 111 male) of 38 index patients with idiopathic dilated cardiomyopathy by clinical examination, electrocardiography, and two-dimensional, M-mode and Doppler echocardiography. Seven relatives (3%) from six families were shown to have dilated cardiomyopathy. Thus, 6 of the 38 index patients (16%) had familial disease. Furthermore, left ventricular enlargement either during diastole or systole was found in 66 of 174 healthy relatives (38%). This is significantly more frequent than in our normal control population of 100 unrelated subjects studied in the same way (18%; P < .0001). These 66 relatives with left ventricular enlargement belonged to 27 of the 38 examined families (71%). Dilated cardiomyopathy was found to be familial in 16% of patients. Of the relatives examined, 41% had left ventricular abnormalities. These findings provide further evidence for a genetic background of dilated cardiomyopathy. Relatives with left ventricular enlargement may have an early stage and/or latent form of the disease.