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European Journal of Heart Failure 2005 7(4):485-489; doi:10.1016/j.ejheart.2004.07.017
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© 2005 European Society of Cardiology

Right ventricular dysfunction in chronic heart failure patients

Lenka Spinarová*, Jaroslav Meluzín, Jirí Toman, Petr Hude, Jan Krejcí and Jirí Vítovec

1st Cardio-angiologic Department, University Hospital Pekarská 53, 656 91 Brno, Czech Republic

* Corresponding author. Tel./Fax: +420 54318 2212. E-mail address: lenka.spinarova{at}fnusa.cz


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Aim: To evaluate any differences in haemodynamic and echocardiographic parameters in patients with both left (LV) and right ventricular (RV) systolic dysfunction and in patients with isolated LV systolic dysfunction.

Study group: One hundred patients with RV systolic dysfunction defined as peak velocity of tricuspid annular motion in systole (Sa)<11.5 cm/s, and 55 patients without RV systolic dysfunction Sa>11.5 cm/s. All patients had LV systolic dysfunction, LV ejection fraction (EF) below 40%, NYHA II–IV.

Methods: LV diameters, volumes and EF were measured by echocardiography. Patients underwent tissue Doppler imaging (TDI) of tricuspid annular motion with measurement of peak systolic velocity (Sa), peak early (Ea) and peak late (Aa) diastolic velocities. Right heart catheterization was also performed.

Results: Patients with RV systolic dysfunction did not differ from those without RV systolic dysfunction in terms of LV function. Patients with RV systolic dysfunction had larger RV dimension 30.6±5.8 vs. 33.9±6.7 mm, p<0.002. The patients with RV systolic dysfunction had higher values on right heart catheterization: MPAP 29.6±12.1 vs. 24.9±11.4 mm Hg, p<0.02, PCWP 20.8±10.0 vs. 17.3±9.3 mm Hg, p<0.03, PVR 189.9±123.3 vs. 137.7±94.9 dyn s cm<5, p<0.008, CVP 7.7±5.6 vs. 5.1±3.9 mm Hg, p<0.002. The patients with RV systolic dysfunction had more pronounced diastolic dysfunction measured by TDI: Ea 9.9±2.3 vs. 11.4±2.5 cm/s, p<0.0001 and Aa 13.1±4.0 vs. 16.5±4.7 cm/s, p<0.000007.

Conclusion: Patients with heart failure and both left and right ventricular systolic dysfunction showed more serious findings on central haemodynamics as well as more pronounced right ventricular diastolic dysfunction than those with isolated left ventricular systolic dysfunction.

Key Words: Right ventricle • Doppler tissue imaging • Tricuspid annulus • Haemodynamics

Received October 8, 2003; Revised January 20, 2004; Accepted July 9, 2004


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Chronic heart failure is a disease process characterized by impaired left ventricular function, increased peripheral and pulmonary vascular resistance and sodium and water retention [1,2].

The worse the failure, the worse the prognosis is [3]. Independent negative prognostic factors are: myocardial function damage (EF below 20%, high systemic arterial resistance, low cardiac output), low peak oxygen consumption (pVO2 below 14 ml/kg/min), hyponatremia below 135 mmol/l, age, diagnosis of coronary artery disease and increased cardiothoracic ratio [4]. Neurohumoral markers: high level of norepinephrine, atrial natriuretic peptide or its precursor N terminal fragment proANP, big endothelin and tumor necrosis factor alpha also have a high negative predictive value [5,6]. Di Salvo et al. [7] recently demonstrated the independent prognostic value of right ventricular ejection fraction in patients with advanced heart failure. The same result was obtained by de Groote for patients with moderate heart failure [8].

In our recent study, we showed that the evaluation of peak systolic tricuspid annular velocity using tissue Doppler imaging provides a simple, rapid and non-invasive tool for assessing right ventricular function in patients with chronic heart failure [9]. Using this methodology differences in haemodynamic and echocardiographic parameters between patients with isolated left ventricular systolic dysfunction and those with systolic dysfunction of both the left and right ventricle were investigated.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
2.1. Study population
The study included 155 patients with left ventricular (LV) systolic dysfunction, defined as an ejection fraction (EF) below 40%. All patients had symptomatic chronic heart failure NYHA class II–IV. The inclusion criteria were as follows: (a) good quality echocardiographic imaging of tricuspid annular motion, (b) sinus rhythm at electrocardiography and (c) clinically stable. The etiology for heart failure was coronary artery disease (defined as 70% angiographically verified luminal narrowing in at least one major coronary artery or documented myocardial infarction) (86 patients) or dilated cardiomyopathy (69 patients). The diagnosis of dilated cardiomyopathy was made based on echocardiographic and clinical criteria. There were 129 men and 26 women, mean age 52±9 years. Of 155 patients with chronic heart failure, 100 exhibited right ventricular (RV) systolic dysfunction defined as peak velocity of tricuspid annular motion in systole (Sa)<11.5 cm/s (Group A), and 55 patients did not have RV systolic dysfunction Sa>11.5 cm/s (Group B).

All patients gave their written consent to the investigations. The study complied with the Declaration of Helsinki and was approved by the institutional ethics committee.

2.2. Echocardiography
Standard and tissue Doppler echocardiograms were obtained in all the patients using SONOS 5500 (Hewlett Packard, Andover, MA,USA) equipment with a phased array transducer of 2.5 MHz and Doppler tissue imaging technology. A detailed description of this technique has been given previously [10]. Minimal gain was used to assure clear and well-defined pulsed Doppler tissue imaging borders. Doppler tissue measurements were acquired with subjects in the left lateral decubitus position during shallow respiration or end-expiratory apnoea.

Guided by two-dimensional four-chamber view, a sample volume with a fixed length of 0.52 cm was placed on the tricuspid annulus at the place of attachment of the anterior leaflet of the tricuspid valve. Care was taken to obtain an ultrasound beam parallel to the direction of the tricuspid annular motion. Peak systolic (Sa), peak early (Ea) and late (Aa) diastolic annular velocities, along with simultaneous electrocardiography, were recorded on a videotape at a speed of 50 mm s–1 for subsequent analysis. A systolic annular velocity<11.5 cm s–1 predicted right ventricular dysfunction (ejection fraction<45%) with a sensitivity of 90% and specificity of 85% [9].

We used a cut off value of 45% for right ventricular dysfunction on the basis of the study by Tokgozoglu [11]. This study evaluated right ventricular function in healthy subjects with no cardiac disease, by echocardiography and radionuclide ventriculography. The lower limit for normal RV function was 45%. The same cut off was used in our previous study [9].

When evaluating peak systolic velocity, the initial peak occurring in the course of isometric contraction was ignored. All pulsed Doppler tissue imaging parameters were measured on three to five consecutive heart cycles. In addition to pulsed Doppler tissue imaging, conventional echocardiography was performed, including M-mode and two-dimensional echocardiography. The right ventricular and left ventricular diameters, and septal and posterior wall thickness were measured according to the recommendations of the American Society of Echocardiography, and left ventricular ejection fraction was calculated using the biplane method according to the modified Simpson's rule [12].

2.3. Right heart catheterization
Right heart catheterization was performed via the right subclavian vein. A 7F thermodilution catheter (model 131HF7, Barter Healthcare Corporation, Irvine, CA, USA) was inserted through the right cavities and the pulmonary artery into the pulmonary wedge position. The measurements of mean right atrial pressure, mean pulmonary artery pressure and mean pulmonary capillary wedge pressures were obtained with the patient in a supine position using a mechanoelectrical transducer (model P23XL, Ohmeda Medical Devices Division, Oxnard, CA, USA) connected to a bedside monitor (model 90308, SpaceLabs, Redmond, WA, USA). Cardiac output was measured by the termodilution technique. The termodilution curve was recorded and calculated using a thermodilution module of the above-mentioned monitor. The cardiac index was calculated as follows: cardiac index (l min–1 m–2)=cardiac output (l min–1)/body surface area (m2).

2.4. Statistical analysis
Clinical, echocardiographic and right heart catheterization data are expressed as mean±standard deviation. Comparison between Groups A and B was done using a two-tailed t-test.

A p value <0.05 was regarded as statistically significant.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
3.1. Characteristics of the study group
The baseline clinical and demographic data are shown in Table 1. The groups were comparable for age, gender and etiology of heart failure.


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  		Table 1 Baseline characteristics of the study population

 
3.2. Echocardiography
Table 2 shows standard echocardiographic and pulsed Doppler tissue imaging measurements. There were no differences between the groups for left ventricular dimensions and volumes. However, patients with right ventricular systolic dysfunction had significantly different dimensions of the right ventricle.


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  		Table 2 Echocardiographic data

 
Patients with right ventricular systolic dysfunction also showed lower peak early (Ea) and late (Aa) diastolic velocities of tricuspid annular motion.

3.3. Right heart catheterization
Patients with the right ventricular dysfunction had higher central venous pressure, pulmonary vascular resistance, mean pulmonary artery and wedge pressures as shown in Table 3.


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  		Table 3 Right heart catheterization data

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
Tissue Doppler imaging has evolved to become a useful non-invasive method for the assessment of left and right myocardial velocities in a variety of clinical conditions. It can be used to assess global and regional systolic function and to identify abnormal relaxation [13].

Doppler tissue imaging has been shown to be very sensitive in the early detection of the right ventricular diastolic dysfunction in patients with Chagas' disease, in contrast to parameters of right inflow pulsed wave Doppler. Although the patients and controls showed normal right ventricular filling dynamics by conventional pulsed Doppler, 44% of the Chagas' disease group presented with an abnormal ratio: early diastolic myocardial velocity/late diastolic myocardial velocity (Em/Am) compared with only one of the control group [14].

The utility of Doppler tissue imaging of tricuspid annular motion for the non-invasive assessment of right ventricular systolic function was demonstrated in our previous study. The peak systolic tricuspid annular velocity significantly correlates with the right ventricular ejection fraction assessed by first-passed radionuclide ventriculography, and a value <11.5 cm/s predicts the presence of right ventricular systolic dysfunction (ejection fraction< 45%) with a sensitivity of 90% and specificity of 85%. Good quality recording can be obtained in more than 95% patients [9]. This method has been accepted as a convenient means of quantitatively evaluating right ventricular systolic function, and has been used as a diagnostic tool by a number of groups [15].

The method is quick, noninvasive, inexpensive and widely available. Based on this methodology, our patients were divided into those with and those without right ventricular systolic dysfunction.

In the trial by Alam et al. myocardial velocities of the mitral and tricuspid annulus were studied in chronic heart failure patients and compared with healthy controls. Patients with chronic heart failure had significantly decreased mitral and tricuspid systolic velocities compared with healthy controls. The early diastolic velocity was also reduced in patients compared with healthy controls for both, mitral and tricuspid annuli [16]. In our study we also found reduced peak early diastolic velocity of tricuspid annular motion in patients with concomitant RV systolic dysfunction compared to patients with normal RV systolic function.

Patients with right ventricular systolic dysfunction also had higher central venous pressure, pulmonary vascular resistance, mean pulmonary artery and wedge pressures.

In the study by di Salvo, the major finding was the importance of right ventricular function for predicting both overall and event-free survival in patients with advanced heart failure.

Preserved rest or exercise right ventricular ejection fraction was found to predict both overall and event-free survival better than peak VO2 [7]. The same result was obtained by de Groote for patients with moderate heart failure [8].

The right ventricle is very sensitive to load and systolic pulmonary artery pressure is an important determinant of right ventricular function. A significant but weak correlation between right ventricular ejection fraction and systolic pulmonary artery pressure in patients with moderate heart failure was reported [8].

The presence of right ventricular dysfunction with pre-existing left ventricular dysfunction is also associated with higher plasma brain natriuretic peptide (BNP) levels, compared to patients with isolated left ventricular dysfunction. Among patients with a left ventricular ejection fraction below 40%, plasma BNP levels were significantly higher in patients with right ventricular ejection fraction below 40% (p<0.004) [17].

All these findings support the idea that the presence of the right ventricular systolic dysfunction is connected with adverse haemodynamic and humoral response and survival. Therefore, it is highly important to evaluate right ventricular function in patients with chronic heart failure. The prognostic importance of tissue Doppler imaging of tricuspid annular motion was shown in our recently published paper [18]. Patients with lower Sa (<l0.8 cm/s) exihibited worse survival p<0.048 and event free survival p<0.001 compared with those having Sa>10.8 cm/s. Risk values of Sa<10.8 cm/s and left ventricular end-diastolic diameter (>70 mm) were found to be additive, leading to a very poor prognosis. Taking into account the fact that an Sa value of 11.5 cm/s divides patients into those with normal or abnormal right ventricular systolic function, the cohort of patients with Sa<10.8 cm/s represents those with moderate or severe right ventricular dysfunction.

4.1. Limitations of the study
The echocardiographic and haemodynamic parameters were not obtained simultaneously, but within a time interval of 20–24 h. However, in view of the stable condition of the patients, we do not think that this could significantly influence our results. Another limitation is the fact that patients were required to be in sinus rhythm for inclusion in the study.

4.2. Conclusion
This study demonstrates the utility of Doppler tissue imaging of tricuspid annular motion for the non-invasive evaluation of the right ventricular function.

Patients with heart failure and right ventricular systolic dysfunction showed more serious findings for central haemodynamics and also more pronounced right ventricular diastolic dysfunction.


   Acknowledgements
 
This work was supported by grant of Education of the Czech Republic (MSM No 14100004) and by grant of Ministry of Health of the Czech Republic (IGA No NA/7619-3).


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 

  1. Coats A.J. Controversies in the management of heart failure (1997) Churchill Livingstone. 180.
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  6. Pacher R., Stanek B., Huelsman M., et al. Prognostic impact of big endothelin-1 plasma concentrations compared with invasive hemodynamic evaluation in severe heart failure. J. Am. Coll. Cardiol. (1996) 27(3):633–641.[Abstract]
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  9. Meluzín J., spinarová L., Bakala J., et al. Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion. A new, rapid, an non-invasive method for evaluating right ventricular systolic function. Eur. Heart J. (2001) 22:340–348.[Abstract/Free Full Text]
  10. Miytake K., Yamagishi M., Tahala N., et al. New method for evaluating left ventricular wall motion by color-coded tissue Doppler imaging:In vitro and in vivo studies. J. Am. Coll. Cardiol. (1995) 25:717–724.[Abstract]
  11. Tokgozoglu S.L., Caner B., Kabakci G., Kes S. Measurement of RV ejection fraction by contrast echocardiography. IJC (1997) 59:71–74.[Medline]
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  16. Alam M., Wardell J., Andersson E., Nordlander R., Samad B. Assessment of left ventricular function using mitral annular velocities in patients with congestive heart failure with or without the presence of significant mitral regurgitation. J. Am. Soc. Echocardiogr. (2003) 16:240–245.[CrossRef][Web of Science][Medline]
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