Right Ventricular Failure in Patients With Preserved Ejection Fraction and Diastolic Dysfunction: An Underrecognized Clinical Entity

Abstract

It is well recognized that patients with severe left ventricular (LV) systolic dysfunction develop pulmonary venous hypertension or postcapillary pulmonary hypertension, which leads to an increase in pulmonary vascular resistance (PVR) and right ventricular (RV) systolic failure. It is often underrecognized, however, that patients with heart failure with preserved LV ejection fraction and diastolic dysfunction may also develop postcapillary pulmonary hypertension with elevated PVR leading to RV systolic failure. This form of biventricular failure is a result of diastolic failure on the left in patients with preserved LV ejection fraction and systolic failure on the right. At this time, there are no randomized trials or guidelines addressing the management of patients with diastolic heart failure with and without resultant RV failure. The authors review the pathophysiology, clinical presentation, and suggested treatment of this underrecognized clinical entity.

Is hydrotherapy an appropriate form of exercise for elderly patients with biventricular systolic heart failure?

“…Theoretically, the elevated pressure during WWI in this patient might be caused by enhanced pulmonary blood flow due to increased venous return. In combination with backward failure of the left ventricle, this could lead to an increase in pulmonary vascular resistance and worsening in RV systolic heart failure [13]. Therefore, it appears that the right ventricle failed to generate enough pressure to overcome RV afterload and thus resulted in further decompensation.…”

Right ventricular remodelling in systemic hypertension: a cardiac MRI study

“…Similar conclusions can be drawn from the strong, positive association of right ventricular EF with its left-sided counterpart, not surprising because the two ventricles share common circular and spiral muscle fibre bundles, and the septal wall, a structure involved in both right ventricular ejection and filling and ventricular interdependence, ie, the transmission of forces from one to the other ventricle independent of neural, humoural or circulatory influences 35. Ventricular interdependence, however, may be overcome by contrasting pathophysiological mechanisms by which right ventricular EF may be preserved in left ventricular dysfunction36 and, vice versa, maintained systolic left ventricular function may coexist with right ventricular failure 37…”

Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath

“…Prior literature has shown that patients with RV dysfunction or overload have worse outcomes. In patients with left heart failure or COPD, RV dysfunction or overload is associated with increased acute exacerbations and increased hospital readmissions compared with patients with normal RV function [7,21,22]. Patients with pulmonary hypertension complicated by RV dysfunction generally have a significantly poorer prognosis and decreased longevity [12,13,15].…”

“…Right ventricular dysfunction may originate from intrinsic muscle damage caused by ischemia or cardiomyopathies. More commonly, however, RV dysfunction occurs from increases in RV afterload, caused by treatable etiologies such as chronic obstructive pulmonary disease, obstructive sleep apnea, pulmonary arterial hypertension, or pulmonary hypertension secondary to left heart disease or chronic thromboemboli [7][8][9][10][11][12][13]. Detection of RV dysfunction from pulmonary hypertension is frequently underdiagnosed.…”

“…Detection of RV dysfunction from pulmonary hypertension is frequently underdiagnosed. Once recognized, it is usually associated with a delay in evaluation and treatment [7,8,14,15]. Patients with underlying RV dysfunction, including RV dilation with or without RV hypokinesis, have increased morbidity and mortality [7,12].…”