Right Ventricular Function in Cardiovascular Disease, Part I

Abstract

I n 1616, Sir William Harvey was the first to describe the importance of right ventricular (RV) function in his seminal treatise, De Motu Cordis: "Thus the right ventricle may be said to be made for the sake of transmitting blood through the lungs, not for nourishing them." 1,2 For many years that followed, emphasis in cardiology was placed on left ventricular (LV) physiology, overshadowing the study of the RV. In the first half of the 20th century, the study of RV function was limited to a small group of investigators who were intrigued by the hypothesis that human circulation could function adequately without RV contractile function. 3 Their studies, however, were based on an open pericardial dog model, which failed to take into account the complex nature of ventricular interaction. In the early 1950s through the 1970s, cardiac surgeons recognized the importance of right-sided function as they evaluated procedures to palliate right-heart hypoplasia. Since then, the importance of RV function has been recognized in heart failure, RV myocardial infarction, congenital heart disease and pulmonary hypertension. More recently, advances in echocardiography and magnetic resonance imaging have created new opportunities for the study of RV anatomy and physiology.The goal of the present review is to offer a clinical perspective on RV structure and function. In the first part, we discuss the anatomy, physiology, aging, and assessment of the RV. In the second part, we discuss the pathophysiology, clinical importance, and management of RV failure. Anatomy of the RV Macroscopic Anatomy of the RVIn the normal heart, the RV is the most anteriorly situated cardiac chamber and lies immediately behind the sternum. In the absence of transposition of great arteries, the RV is delimited by the annulus of the tricuspid valve and by the pulmonary valve. As suggested by Goor and Lillehi, 4 the RV can be described in terms of 3 components: (1) the inlet, which consists of the tricuspid valve, chordae tendineae, and papillary muscles; (2) the trabeculated apical myocardium; and (3) the infundibulum, or conus, which corresponds to the smooth myocardial outflow region 4,5 (Figure 1). In the study of congenital heart disease, this division seems to be more practical than the traditional division of the RV into sinus and conus components. 5 Additionally, the RV can also be divided into anterior, lateral, and inferior walls, as well as basal, mid, and apical sections. 6 Three prominent muscular bands are present in the RV: the parietal band, the septomarginal band, and the moderator band. The parietal band and the infundibular septum make up the crista supraventricularis. 7 The septomarginal band extends inferiorly and becomes continuous with the moderator band, which attaches to the anterior papillary muscle. 7 When abnormally formed or hypertrophied, the septomarginal band can divide the ventricle into 2 chambers (double-chambered RV). 5 Another important characteristic of the RV is the presence of a ventriculoinfundibular fold that separate...

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