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Importance of Assessing Left Ventricular Function in Right Ventricular Pressure Overload: Evaluation from Viewpoint of Left and Right Heart Interaction
S134 Journal of Cardiac Failure Vol. 17 No. 9S September 2011
Symposium 8 S8-1 Importance of Assessing Left Ventricular Function in Right Ventricular Pressure Overload: Evaluation from Viewpoint of Left and Right Heart Interaction TOSHINORI YUASA1, AKIRA KISANUKI2, SHUICHI HAMASAKI1, CHUWA TEI1 1 Department of Cardiovascular, Respiratory and Metabolic Medicine, Graduate School of Medicene, Kagoshima university, Kagoshima, Japan, 2Department of Health Science, Kagoshima University Hospital, Kagoshima, Japan Background: In patients with pulmonary embolism or pulmonary artery hypertension, increased pulmonary artery resistance causes high pulmonary artery pressure, low cardiac output and tricuspid regurgitation. Some articles reported that right ventricular (RV) function parameters are useful for evaluating the pathology and the prognosis in these patients. On the other hand, right ventricle in pulmonary hypertension often spreads and presses left ventricle. Then, we hypothesized that LV Tei index and other LV parameters are valuable to evaluate the pathology and curative effects in patients with pulmonary embolism. Methods: Nine patients with acute pulmonary embolism were enrolled. Echocardiographic data were analyzed before and after thrombolytic therapy. LV Tei index, isovolumic contraction and relaxation time (ICT, IRT), Ejection time (ET) and each time interval parameters corrected by heart rate (ICTc, IRTc, ETc) were measured as well as RV parameters. Results: 1) Similar to RV Tei index, LV Tei index were significantly improved after thrombolytic therapy (RV Tei index: 0.5660.20 vs. 0.3160.17, p50.009, LV Tei index: 0.5760.10 vs. 0.3860.1, p50.003). 2) LV-IRTc significantly decreased (108625ms vs. 80619ms, p50.03). LV-ETc significantly increased (254637 vs. 322632, p50.001) after thrombolytic therapy. Conclusion: LV Tei index and other LV parameters also can be valuable to evaluate the pathology and curative effects in patients with pulmonary embolism.
S8-2 Right Heart Failure in Pulmonary Arterial Hypertension HIROMI MATSUBARA Division of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan Pulmonary arterial hypertension (PAH) has poor prognosis. The main cause of death in PAH was reported to be right heart failure. As same as in left heart failure, positive inotropic agents cannot improve the patients’ survival, because essential cause of right heart failure associated with PAH should be extremely high afterload of right ventricle (RV). Therefore, sufficient decrease of afterload of RV would be necessary to improve the long term survival of PAH patients. Recently, many PAH specific drugs which have potential to decrease RV afterload have been developed. However, many physicians still believe that once elevated pulmonary arterial pressure of PAH patients cannot be decreased. Thus, too small amount and too small number of PAH specific drugs were prescribed and resulted in little improvement of the patients’ survival. We have introduced aggressive combination therapy with several PAH specific drugs and successfully improved the patients’ long term survival. Today, ten years survival of PAH patients in our institute have reached 80%. Based on our experience, I will present the optimal therapeutic strategy for right heart failure associated with PAH.
S8-3 Role of RV Function in Patients with Advanced Heart Failure and Severe Mitral Regurgitation YASUSHI SAKATA, ISAMU MIZOTE, ISSEI KOMURO Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan The role of RV function is unclear in mortality and morbidity of patients with advanced heart failure. We examined serial 15 patients with NYHA class 3 or 4, LVDd O65mm and severe functional mitral regurgitation (fMR) undergoing mitral valve surgery to elucidate factors associated with poor outcome of mitral valve surgery in patients with refractory heart failure, dilated LV and severe fMR. Five patients had a composite of poor outcomes defined as death, no improvement in NYHA class or HF hospitalization within 6 months. As shown in table, RV diastolic diameter and right atrial pressure tend to show the difference between patients with successful and unsuccessful result in the operation. Therefore, RV function may play an important role in outcome in operated pts with HF, dilated LV and severe fMR.
Preoperative Parameters Successful result (n 5 10) LVDd (mm) LVDs (mm) EF (%) LVEDV (ml) LVESV (ml) TRPG (mmHg) RVDd (mm) mPAP (mmHg) PCWP (mmHg) mRAP (mmHg) mAoP (mmHg) HR at catheterization CO (ml/min)
75.2 67.5 26.3 274 202 32.3 24.7 28.3 19.6 4.7 79.9 80.2 4.0
6 6 6 6 6 6 6 6 6 6 6 6 6
6.4 9.5 8.3 68 60 12.6 6.4 13.4 9.8 3.2 15.4 13.6 1.1
Unsuccessful result (n 5 5)
P value
6 6 6 6 6 6 6 6 6 6 6 6 6
0.09 0.16 0.12 0.18 0.10 0.49 0.02 0.56 0.47 0.07 0.33 0.08 0.37
82.8 75.0 19.4 329 262 37.4 36.6 33.2 23.8 8.2 71.8 66.6 3.4
9.5 8.5 5.7 78 71 14.3 10.5 16.8 11.4 3.3 16.0 10.2 0.9
(mean 6 1SD).
S8-4 Incidence, Clinical Predictors, and Prognosis of Isolated Tricuspid Regurgitation (TR) Late after Mitral Valve Surgery CHISATO IZUMI1, MAKOTO MIYAKE1, SEIKO NAKAJIMA1, MASATAKA NISHIGA1, JIRO SAKAMOTO1, HIROKAZU KONDO1, TOSHIHIRO TAMURA1, KAZUAKI KAITANI1, YOSHIHISA NAKAGAWA1, KAZUO YAMANAKA2 1 Department of Cardiology, Tenri Hospital, 2Department of Cardiovascular surgery, Tenri Hospital Objectives: Severe TR sometimes develops late after mitral surgery without significant left heart failure, pulmonary hypertension or rheumatic tricuspid valve. The purpose of this study is to clarify the frequency, clinical characteristics and prognosis of severe isolated TR late after mitral surgery. Methods: We studied 329patients who underwent mitral surgery between 1985 and 2004, showed no or mild TR early after operation and were followed up with echocardiography for at least 5years. The incidence of severe isolated TR, clinical background, and preoperative echocardiographic data were examined. In patients with severe isolated TR, chronological changes of echocardiographic data, treatment, and prognosis were examined. Results: Mean follow-up period was 11.7years. Severe isolated TR was detected in 26patients (8%). The presence of Af and preoperative EF were independent clinical determinants. Tricuspid annular diameter increased prior to TR progression. Tenting area wasn’t related to the progression of isolated TR. 5-year congestive heart failure free rate after progression of severe TR was 70%. Three patients underwent surgical treatment and the others medical treatment. 5-year and 10-year cardiac death free rate in patients with medical treatment were 91% and 80% respectively. Patients who underwent surgical treatment showed no cardiac death. Conclusions: Af and preoperative EF were clinical determinants for the progression of isolated TR after mitral surgery. Annular dilatation was the main cause of isolated TR.
S8-5 Right Heart Failure in Congenital Heart Disease OSAMU YAMADA, HIDEO OHUCHI, HISASHI SUGIYAMA The Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Japan In contrast to the right heart failure in the acquired heart disease, that in the congenital heart disease (CHD) develops after the chronically accumulated insult of hemodynamic overload. Right ventricle (RV) of the fetal heart in utero, expels blood to the lower body through the ductus arteriosus, so it can generates systemic pressure. Normal neonate RV also is able to develop systemic blood pressure as well, immediately after birth. In correspondence with following rapid decrease of the pulmonary resistance, pressure developing ability (contractility) of the normal RV falls shortly. However, when there is continual requirement of high pressure generation to RV successively after birth from hemodynamic involvement with CHD, RV is easy to make reply without right heart failure. Here, we feature ventricular septal defects with elevated right ventricular pressure (VSD) of infants and younger children and Eisenmenger syndrome (ES) of adolescents and adults. In VSD, RV ejection fraction remains in normal range, regardless of RV systolic pressure, pulmonary resistance or age, on the contrary it is decreased in ES. Although both groups have experienced successive high RV pressure, the duration in either group differs much. Low coronary flow reserve in ES measured by Doppler might explain, in part, the vulnerability of RV myocardium resulted in decreased RV ejection fraction after the repeated imbalance of myocardial energy requirement and supply.
Symposium 8 S8-1 Importance of Assessing Left Ventricular Function in Right Ventricular Pressure Overload: Evaluation from Viewpoint of Left and Right Heart Interaction TOSHINORI YUASA1, AKIRA KISANUKI2, SHUICHI HAMASAKI1, CHUWA TEI1 1 Department of Cardiovascular, Respiratory and Metabolic Medicine, Graduate School of Medicene, Kagoshima university, Kagoshima, Japan, 2Department of Health Science, Kagoshima University Hospital, Kagoshima, Japan Background: In patients with pulmonary embolism or pulmonary artery hypertension, increased pulmonary artery resistance causes high pulmonary artery pressure, low cardiac output and tricuspid regurgitation. Some articles reported that right ventricular (RV) function parameters are useful for evaluating the pathology and the prognosis in these patients. On the other hand, right ventricle in pulmonary hypertension often spreads and presses left ventricle. Then, we hypothesized that LV Tei index and other LV parameters are valuable to evaluate the pathology and curative effects in patients with pulmonary embolism. Methods: Nine patients with acute pulmonary embolism were enrolled. Echocardiographic data were analyzed before and after thrombolytic therapy. LV Tei index, isovolumic contraction and relaxation time (ICT, IRT), Ejection time (ET) and each time interval parameters corrected by heart rate (ICTc, IRTc, ETc) were measured as well as RV parameters. Results: 1) Similar to RV Tei index, LV Tei index were significantly improved after thrombolytic therapy (RV Tei index: 0.5660.20 vs. 0.3160.17, p50.009, LV Tei index: 0.5760.10 vs. 0.3860.1, p50.003). 2) LV-IRTc significantly decreased (108625ms vs. 80619ms, p50.03). LV-ETc significantly increased (254637 vs. 322632, p50.001) after thrombolytic therapy. Conclusion: LV Tei index and other LV parameters also can be valuable to evaluate the pathology and curative effects in patients with pulmonary embolism.
S8-2 Right Heart Failure in Pulmonary Arterial Hypertension HIROMI MATSUBARA Division of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan Pulmonary arterial hypertension (PAH) has poor prognosis. The main cause of death in PAH was reported to be right heart failure. As same as in left heart failure, positive inotropic agents cannot improve the patients’ survival, because essential cause of right heart failure associated with PAH should be extremely high afterload of right ventricle (RV). Therefore, sufficient decrease of afterload of RV would be necessary to improve the long term survival of PAH patients. Recently, many PAH specific drugs which have potential to decrease RV afterload have been developed. However, many physicians still believe that once elevated pulmonary arterial pressure of PAH patients cannot be decreased. Thus, too small amount and too small number of PAH specific drugs were prescribed and resulted in little improvement of the patients’ survival. We have introduced aggressive combination therapy with several PAH specific drugs and successfully improved the patients’ long term survival. Today, ten years survival of PAH patients in our institute have reached 80%. Based on our experience, I will present the optimal therapeutic strategy for right heart failure associated with PAH.
S8-3 Role of RV Function in Patients with Advanced Heart Failure and Severe Mitral Regurgitation YASUSHI SAKATA, ISAMU MIZOTE, ISSEI KOMURO Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan The role of RV function is unclear in mortality and morbidity of patients with advanced heart failure. We examined serial 15 patients with NYHA class 3 or 4, LVDd O65mm and severe functional mitral regurgitation (fMR) undergoing mitral valve surgery to elucidate factors associated with poor outcome of mitral valve surgery in patients with refractory heart failure, dilated LV and severe fMR. Five patients had a composite of poor outcomes defined as death, no improvement in NYHA class or HF hospitalization within 6 months. As shown in table, RV diastolic diameter and right atrial pressure tend to show the difference between patients with successful and unsuccessful result in the operation. Therefore, RV function may play an important role in outcome in operated pts with HF, dilated LV and severe fMR.
Preoperative Parameters Successful result (n 5 10) LVDd (mm) LVDs (mm) EF (%) LVEDV (ml) LVESV (ml) TRPG (mmHg) RVDd (mm) mPAP (mmHg) PCWP (mmHg) mRAP (mmHg) mAoP (mmHg) HR at catheterization CO (ml/min)
75.2 67.5 26.3 274 202 32.3 24.7 28.3 19.6 4.7 79.9 80.2 4.0
6 6 6 6 6 6 6 6 6 6 6 6 6
6.4 9.5 8.3 68 60 12.6 6.4 13.4 9.8 3.2 15.4 13.6 1.1
Unsuccessful result (n 5 5)
P value
6 6 6 6 6 6 6 6 6 6 6 6 6
0.09 0.16 0.12 0.18 0.10 0.49 0.02 0.56 0.47 0.07 0.33 0.08 0.37
82.8 75.0 19.4 329 262 37.4 36.6 33.2 23.8 8.2 71.8 66.6 3.4
9.5 8.5 5.7 78 71 14.3 10.5 16.8 11.4 3.3 16.0 10.2 0.9
(mean 6 1SD).
S8-4 Incidence, Clinical Predictors, and Prognosis of Isolated Tricuspid Regurgitation (TR) Late after Mitral Valve Surgery CHISATO IZUMI1, MAKOTO MIYAKE1, SEIKO NAKAJIMA1, MASATAKA NISHIGA1, JIRO SAKAMOTO1, HIROKAZU KONDO1, TOSHIHIRO TAMURA1, KAZUAKI KAITANI1, YOSHIHISA NAKAGAWA1, KAZUO YAMANAKA2 1 Department of Cardiology, Tenri Hospital, 2Department of Cardiovascular surgery, Tenri Hospital Objectives: Severe TR sometimes develops late after mitral surgery without significant left heart failure, pulmonary hypertension or rheumatic tricuspid valve. The purpose of this study is to clarify the frequency, clinical characteristics and prognosis of severe isolated TR late after mitral surgery. Methods: We studied 329patients who underwent mitral surgery between 1985 and 2004, showed no or mild TR early after operation and were followed up with echocardiography for at least 5years. The incidence of severe isolated TR, clinical background, and preoperative echocardiographic data were examined. In patients with severe isolated TR, chronological changes of echocardiographic data, treatment, and prognosis were examined. Results: Mean follow-up period was 11.7years. Severe isolated TR was detected in 26patients (8%). The presence of Af and preoperative EF were independent clinical determinants. Tricuspid annular diameter increased prior to TR progression. Tenting area wasn’t related to the progression of isolated TR. 5-year congestive heart failure free rate after progression of severe TR was 70%. Three patients underwent surgical treatment and the others medical treatment. 5-year and 10-year cardiac death free rate in patients with medical treatment were 91% and 80% respectively. Patients who underwent surgical treatment showed no cardiac death. Conclusions: Af and preoperative EF were clinical determinants for the progression of isolated TR after mitral surgery. Annular dilatation was the main cause of isolated TR.
S8-5 Right Heart Failure in Congenital Heart Disease OSAMU YAMADA, HIDEO OHUCHI, HISASHI SUGIYAMA The Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Japan In contrast to the right heart failure in the acquired heart disease, that in the congenital heart disease (CHD) develops after the chronically accumulated insult of hemodynamic overload. Right ventricle (RV) of the fetal heart in utero, expels blood to the lower body through the ductus arteriosus, so it can generates systemic pressure. Normal neonate RV also is able to develop systemic blood pressure as well, immediately after birth. In correspondence with following rapid decrease of the pulmonary resistance, pressure developing ability (contractility) of the normal RV falls shortly. However, when there is continual requirement of high pressure generation to RV successively after birth from hemodynamic involvement with CHD, RV is easy to make reply without right heart failure. Here, we feature ventricular septal defects with elevated right ventricular pressure (VSD) of infants and younger children and Eisenmenger syndrome (ES) of adolescents and adults. In VSD, RV ejection fraction remains in normal range, regardless of RV systolic pressure, pulmonary resistance or age, on the contrary it is decreased in ES. Although both groups have experienced successive high RV pressure, the duration in either group differs much. Low coronary flow reserve in ES measured by Doppler might explain, in part, the vulnerability of RV myocardium resulted in decreased RV ejection fraction after the repeated imbalance of myocardial energy requirement and supply.