Effect of Valsartan on Systemic Right Ventricular Function

Abstract

Editorial see p 314 Clinical Perspective on p 330In both asymptomatic and symptomatic patients with systemic left ventricular dysfunction, inhibition of the reninangiotensin aldosterone system (RAAS) decreases both Background-The role of angiotensin II receptor blockers in patients with a systemic right ventricle has not been elucidated. Methods and Results-We conducted a multicenter, double-blind, parallel, randomized controlled trial of angiotensin II receptor blocker valsartan 160 mg twice daily compared with placebo in patients with a systemic right ventricle caused by congenitally or surgically corrected transposition of the great arteries. The primary end point was change in right ventricular ejection fraction during 3-year follow-up, determined by cardiovascular magnetic resonance imaging or, in patients with contraindication for magnetic resonance imaging, multirow detector computed tomography. Secondary end points were change in right ventricular volumes and mass, V · o 2 peak, and quality of life. Primary analyses were performed on an intention-to-treat basis. A total of 88 patients (valsartan, n=44; placebo, n=44) were enrolled in the trial. No serious adverse effects occurred in either group. There was no significant effect of 3-year valsartan therapy on systemic right ventricular ejection fraction (treatment effect, 1.3%; 95% confidence interval, −1.3% to 3.9%; P=0.34), maximum exercise capacity, or quality of life. There was a larger increase in right ventricular end-diastolic volume (15 mL; 95% confidence interval, 3-28 mL; P<0.01) and mass (8 g; 95% confidence interval, 2-14 g; P=0.01) in the placebo group than in the valsartan group. Conclusions-There was no significant treatment effect of valsartan on right ventricular ejection fraction, exercise capacity, or quality of life. Valsartan was associated with a similar frequency of significant clinical events as placebo. Small but significant differences between valsartan and placebo were present for change in right ventricular volumes and mass. Clinical Trial Registration-URL: http://www.controlled-trials.com. Unique identifier: ISRCTN52352170. 17,20,21 In asymptomatic patients, on the other hand, there was no effect on ventricular function, and the effect on ventricular remodeling was much less pronounced. [22][23][24] In patients with a systemic right ventricle, the role of pharmacological RAAS blockade has not been established. Because angiotensin II receptor density is similar in both the left and right ventricles, and neurohormonal activity is similar to that observed in patients with stable heart failure, one would expect a similar effect.25-27 However, in 2 small placebo-controlled trials (n=17 and n=29, respectively), RAAS inhibition had no beneficial effect on exercise capacity, right ventricular function, or remodeling. 28,29 These studies, on the other hand, had only short-term follow-up and low patient numbers. Moreover, predominantly asymptomatic patients were included. Results from retrospective and single-arm studies have been eq...

Almanac 2014: congenital heart disease

“…The lack of benefit of renin-angiotensin inhibition for a systemic RV is now corroborated by a larger multicentre, double-blind, parallel, randomised controlled trial involving 88 adults with transposition of TGA. 43 In this study, no effects of valsartan 160 mg twice daily on RV EF or exercise capacity could be demonstrated at 3 years of follow-up.…”

Clinical Characteristics of Adult Patients With Congenital Heart Disease Hospitalized for Acute Heart Failure

“…Similar to HF patients with acquired heart disease, neurohormonal activation has been well demonstrated in patients with CHD. 15 However, efficacy of neurohormonal blockage in patients with CHD remains unclear 16 and must be elucidated.…”

Ventricular Assist Devices in Patients with Systemic Right Ventricular Failure due to Congenitally Corrected Transposition of the Great Arteries

“…Although there are no randomized control trials in this patient population, evidence based therapies in heart failure with reduced ejection fraction have been applied, which include angiotensin converting enzyme inhibitor or angiotensin II receptor blocker and beta-blocker therapies [14][15][16][17][18][19]. There is no evidence for digoxin; however, it can be used.…”