The right ventricle in chronic heart failure ESC 2012 Christian Opitz, Berlin
There are no conflicts of interest relevant to this presentation
Percent of Population Prevalence of Heart Failure by Age and Sex NHANES: 1999-2002 11 9 7 5 3 1-1 0,3 0,3 0,5 0,4 1,8 1,5 5,8 2,3 6,2 4,1 10,9 9,8 20-34 35-44 45-54 55-64 65-74 75+ Men Ages Women 23 million CHF pts. worldwide Increasing with age Depending on estimated proportion and definition 30-80% of these pts. potentially have pulmonary hypertension Cardiovascular Disease Deaths vs. Cancer Deaths by Age United States: 2003 * Deaths in Thousands 900 800 700 600 500 400 300 200 100 0 5 3 4 4 17 15 46 50 80 95 282 141 167 138 <25 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total 338 80 911 555 CVD Cancer Source: CDC/NCHS and NHLBI.
How important is RV function in CHF? 34 CHF pts., IHD, LVEF < 40% radionuclide RVEF and survival @ 24 months LVEF RVEF Alive Dead Alive Dead Polak,..., Colucci, JACC 1983
How important is RV function in CHF? 67 CHF pts., LVEF 22±7% radionuclide RVEF and CPX vs. survival multivariate analysis: RVEF >35% (@exercise) as independent predictor RVEF >35% (@rest) RVEF <35% (@rest) Di Salvo, JACC 1995
How important is RV function in CHF? 379 CHF pts., LVEF< 35 %, DCMP & IHD, optimized therapy, RHC with thermodilution-rvef PAP+RVEF normal PAP+RVEF reduced Ghio, JACC 2001
How important is PH in CHF? Guazzi, Circ 2012 (Abramson 92, Lam 09)
How frequent is PH in CHF? HF with reduced LVEF 379 CHF pts. LVEF< 35 %, DCMP & IHD optimized therapy RHC with thermodilution-rvef HF with preserved LVEF 244 pts. w HFpEF (76±13 yrs., 45% male) PH defined as: Echo PASP > 35 mmhg 62% with PAPm > 20 mmhg Ghio et al. JACC 2001;37:183-8, Lam JACC 2009
RVEF and CHF 2008 pts. from the BEST-Study (Bucindolol vs Pl, 60±12 yrs, LVEF < 35%, NYHA III/IV) Radionuclide RVEF and survival @ 24 months Normal RVEF in 37% of all pts. (higher LVEF, shorter disease duration) RVEF <20% independently predicted mortality 60% Meyer, Circ 2010
RV-Volumes and CHF: MRI 380 CHF pts. (LVEF<45%) vs. 80 controls dilated RV in 25% of pts. RVESVI independently predicted mortality (when clinical signs of fluid overload are excluded) Bourantas, EJHF 2011
Mechanisms and Causes of RV Failure Pressure overload Left-sided HF (most common cause), Pulmonary embolism (common), Other causes of PH, RV outflow tract obstruction, Peripheral pulmonary stenosis, Double-chambered RV, Systemic RV Volume overload Tricuspid regurgitation, Pulmonary regurgitation, Atrial septal defect, Anomalous pulmonary venous return, Sinus of valsalva rupture into the RA, Coronary artery fistula to RA or RV, Carcinoid syndrome, Rheumatic valvulitis Ischemia and infarction RV myocardial infarction, Ischemia may contribute to RV dysfunction in CHD and RV overload states (especially pressure overload) Intrinsic myocardial process Cardiomyopathy and heart failure, Arrhythmogenic RV dysplasia, Sepsis Inflow limitation Tricuspid stenosis, Superior vena cava stenosis Complex congenital defect Ebstein s anomaly, Tetralogy of Fallot, Transposition of the great arteries, Double-outlet RV with mitral atresia Pericardial disease Constrictive pericarditis Haddad, Circ 2008
Mechanisms and Causes of RV Failure Pressure overload Left-sided HF (most common cause), Pulmonary embolism (common), Other causes of PH, RV outflow tract obstruction, Peripheral pulmonary stenosis, Double-chambered RV, Systemic RV Volume overload Tricuspid regurgitation, Pulmonary regurgitation, Atrial septal defect, Anomalous pulmonary venous return, Sinus of valsalva rupture into the RA, Coronary artery fistula to RA or RV, Carcinoid syndrome, Rheumatic valvulitis Ischemia and infarction RV myocardial infarction, Ischemia may contribute to RV dysfunction in CHD and RV overload states (especially pressure overload) Intrinsic myocardial process Cardiomyopathy and heart failure, Arrhythmogenic RV dysplasia, Sepsis Inflow limitation Complex congenital defect Tricuspid stenosis, Superior vena cava stenosis Left-sided Heart Failure (most common cause) Ebstein s anomaly, Tetralogy of Fallot, Transposition of the great arteries, Double-outlet RV with mitral atresia Pericardial disease Constrictive pericarditis Haddad, Circ 2008
The RV is afterload-sensitive Abel, JTCS 1967 (modified)
RV afterload: resistance and compliance Retrospective database analysis of > 8000 pts. With increasing PCWP capacitance in the PA disproportionally decreased thereby increasing pulsatile load more than resistive load for the RV Tedford, Circ 2012
Exercise and PH in CHF 60 CHF pts. (LVEF 31±7%) and 60 controls underwent CPX with RHC controls CHF Lewis, Circ Heart Fail 2011
Exercise and PH in CHF 60 CHF pts. (LVEF 31±7%) underwent CPX with RHC Lewis, Circ Heart Fail 2011
Exercise and PH in CHF 60 CHF pts. (LVEF 31±7%) underwent CPX with RHC abnormal precapillary response Lewis, Circ Heart Fail 2011
High PAP / PVR Price, Crit Care 2010 (modified)
RV LV RV LV CHF PH (forward) stroke volume : RV = LV
RV LV RV LV CHF PH
Ventricular Interdependence Guazzi, Circ 2012
Ventricular Interdependence 21 CHF pts. 12 controls: 30 minutes lower-body suction Atherton, Lancet 1997
RV- follows LV-dysfunction? 1547 pts. with suspected CHF (EKG, Echo, BNP) RV- and LV-function are correlated with LVEF<45% TAPSE reduced in 70% Damy, Journal of Cardiac Failure Vol. 18 No. 3 2012
TAPSE and Survival Damy, Journal of Cardiac Failure Vol. 18 No. 3 2012
RV-function and PAP Damy, Journal of Cardiac Failure Vol. 18 No. 3 2012
Can PH predict HF? 1045 pts. with acute MI (day 2-3), Echo: PAPs > 35 mmhg? PE: admission for HF @ 1 yr. PH present in 45%, related to age, LVEF, diastolic dysfunction, MR Mutlak, Am J Cardiol 2012
Can PH predict HF? 1045 pts. with acute MI (day 2-3), Echo: PAPs > 35 mmhg? PE: admission for HF @ 1 yr. PH present in 45%, related to age, LVEF, diastolic dysfunction, MR Mutlak, Am J Cardiol 2012
Can PH predict HF? PASP integrates the severity of multiple hemodynamic determinants of increased left atrial pressures that lead to an increase in pulmonary venous pressure. useful marker in predicting the development of overt HF? Mutlak, Am J Cardiol 2012
Can PH predict HF decompensation? 16 pts., LVEF 23±11%, NYHA II-III, one previous decompensation epad = estimated diastolic PAP Vanderheyden, Circulation: Heart Failure. 2010;3:370-377
The RV in CHF LV dysfunction frequently induces PH PH is a negative prognostic sign in CHF RV dysfunction and dilatation indicate impaired survival Both reduce functional capacity PH can precede overt heart failure
Treatment? 46 pts. CHF NYHA II / III, LVEF <45%, ICMP or DCMP 6 months Sildenafil 3 x 50 mg vs. Placebo Guazzi JACC 2007
Peak VO2 (mlo2/kg/min) 20 19 18 17 16 15 14 13 12 11 10 * * 18,5 18,7 15,3 14,9 15,1 14,8 Baseline 3 Monate 6 Monate Placebo Sildenafil * p<0.01 Guazzi JACC 2007
Wireless pulmonary artery haemodynamic monitoring in CHF: a randomised controlled trial Abraham, Lancet 2011
Treatment-goal: normalize PAP Optimized medical CHF-Therapy no pulmonary vasodilators Abraham, Lancet 2011
Effect on readmission or mortality Abraham, CHAMPION Trial, Lancet Abraham, 10.02.2011 Lancet 2011
Conclusion The role of the RV and PH in CHF is increasingly appreciated and studied The assessment of RV function (and PH) should be part of the diagnostic work-up in CHF patients Whether targeted treatment of PH in CHF patients will improve morbidity and mortality has to be shown in RCT