Download Mechanism of PH in CHF

RV function
Prognostic implications in heart failure
Efthimios Anagnostou M.D.
No disclosures
The prognostic value of RV function in
cardiovascular disease.
After AMI
Congestive HF
Valvular HD
Congenital HD
After HT
Pulmonary Embolism
Pulmonary HTN
HFpEF
reduced RVEF is an independent prognostic
factor in moderate to severe CHF.
Courtesy C.Celton-Saty
RVEF predicts prognosis in CHF
RVEF: Prognostic impact late after AMI
147 Pts, late after MI , RVEF<40%
CMR RVEF and survival @ 17 months
RVEF≥40%
Larose
RVEF<40%
Larose JACC 2007
Better survival & Better exercise capacity
RV function + PH predict survival in CHF
379 CHF pts, LVEF<35% ,DCM & IHD, optimized Rx
RHC with thermodilution RVEF
Normal PAP +Normal RVEF
High PAP +Low RVEF
Ghio, JACC 2001
RV dilatation predicts survival in CHF
380 CHF pts, LVEF<45% VS controls
DILATED RV IN 25% of pts
RVESVi: independent predictor of mortality
Bourantas EJHF 2011
Despite…
•variations in study populations,
•severity and substrates of disease,
•methodologies of assessment.
RV dysfunction portends
an
inferior survival.
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Insidiously ignored until
the BEST trial…
distribution of RVEF in CHF
2008 pts, from the BEST study, LVEF<35%,NYHA III/IV
Radionuclide RVEF and mortality @ 24 months
Mortality 47%
=63%
Mortality 27%
=37%
Meyer et al, Circulation 2012
What is RV failure ?
Inability
of the RV
to maintain
outputis
an
Increased
Preload
(RAcardiac
pressure)
through the pulmonary vascular bed
at normal
venous
pressures.CO
required
tocentral
maintain
adequate
The commonest cause of RV Dysfunction is
Left Heart Disease
LV Systolic Dysfunction
CAD
Valve Disease
LV Diastolic Dysfunction
Hypertension
Restrictive Cardiomyopathy
HCM
HFrEF
HFpEF
CHF causes Pulmonary
GroupHypertension
2 PH
leading to
Ventricular
mPA>25mmHgRight
PCWP
>15mmHgFailure
CO normal or low
MV
disease
PAP
PCWP
HTN
LA
pressure
AoV
disease
HFpEF
HFrEF
Mechanism of PH in CHF
1000 CHF pts undergoing transplant evaluation
Drazner J Heart Lung Transplant 1999
Correlation nice and straight and fairly tight indicating therefore that PAP is driven passively by PCWP
Mechanism of PH in CHF
intimal
Fibrosis
PCWP
PAP
This may or may not result in rise in the PAP with a consequent rise in the TPG or PVR
Different Hemodynamic Stages in GROUP 2 PH
Mechanism of PH in CHF
1000 CHF pts undergoing transplant evaluation
Drazner J Heart Lung Transplant 1999
because of vascular changes in the arterial side of pulmonary circulation
CHF, PH+
CHF, PH-
This ismedial
NOT, however,
idiopathic
PAHpulmonary
(a vascular
proliferative
Marked
hypertrophy
of a muscular
artery
in a patient disease)
with CHF,
compared
to another
of similar
size with
minimal medial
in a patient
with
but rather
a secondary
medial
hypertrophy
of thickening
the pulmonary
arteries
CHF but not pulmonary hypertension
A RESPONSE TO PREVENT ALVEOLAR EDEMA FROM HAPPENING
Mechanism of PH in CHF
PCWP
PAP
As a consequence of rise in PAP, PVR and PVH, the RV runs into trouble
PH and impaired Exercise capacity in CHF
320 pts
Di Salvo JACC 1995
a consequence of rise in PVR is the dramatic decrease in CO both
at rest and during exercise
ADULT HEART TRANSPLANTATION
Kaplan Meyer estimates of mortality 1999-2007
stratified by PVR
< 2 WU
2- 4 WU
> 4 WU
Ventricular Interdependence
RV stroke volume predicts prognosis in PAH
64 pts, CMR, RHC, 6MWT
Wolferen, EHJ 2007
RVH
RV failure
RV dilatation
RA dilatation
D-shaped LV
Tricuspid
Regurgitation
The shrinking LV…
This is the beginning
This is the end, my friend
HFpEF
PASP estimates are a risk factor for death.
Markers of RV Dysfunction
associated with clinical status and prognosis
Systolic Performance
Diastolic Filling
RVEF
Tissue Doppler indices
RVFAC
Isovolumic acceleration
TAPSE
Syst/Diast myocardial velocities
RV MPI
Hemodynamics
Right-sided Dilation
RV dilation absolute/ relative to LV
RA pressure
RA size
CI
TR
Maximal dP/dT
Pressure–volume Measurements
Ventricular elastance
Preload recruitable stroke work
We would be poorly served by buying
into the concept that an RVEF is the
only ‘‘reference standard,’’ without
recognition of its shortcomings.
However,
our results
also showed
that RV volume
measurements
Multimodality
Comparison
of Quantitative
Volumetric
Analysis
are not interchangeable
between
modalities and, therefore,
of the
Right Ventricle
serial evaluations should be performed using the same modality.
Sugeng, JACC im g 201 0
When grappling with what measure
should be adopted to evaluate RV
systolic function, we are left with the
classic answer:
it depends!
Conclusions
RV dysfunction is a strong parameter of
functional capacity
RV dysfunction is prognostically superior to
LV parameters of systolic/diastolic function
RV dysfunction is present in about two-thirds
of patients with CCF and doubles mortality
RV dilatation has the worst prognosis
RV assessment is a must of the diagnostic
work-up in CCF patients
Thank you
The myocardium of the entire heart is now known to be a
single sheet of muscle rolled into different chambers
http://www.youtube.com/watch?v=Mih37LLv6IQ&feature=plcp