Skip to main content
SpringerLink
Log in

Ischemic right ventricular dysfunction

  • Published:
Cardiovascular Drugs and Therapy Aims and scope Submit manuscript

Summary

For many years ischemic heart disease involving the right ventricle had received little attention. During the last 15 years, the initial works of Cohn, Isner, and others spawned a number of clinical and experimental studies that extended the understanding of the pathophysiology of ischemia in the right ventricle. Most of the work has been done in the setting of acute myocardial infarction, and information is still lacking in other conditions, such as chronic ischemic heart disease and perioperative right ventricular dysfunction. Acute right ventricular infarction rarely occurs in the absence of left ventricular necrosis and in most cases is the extension of an inferior left ventricular infarct. The majority of patients with right ventricular infarction only exhibit subtle signs of ischemic dysfunction. Elevated right atrial pressure is found only in the typical syndrome of elevated venous pressure; low output syndrome can be found only in 20% of the cases, and cardiogenic shock secondary to right ventricular necrosis is found only in 10%. It is also important to note that there is not a clear correlation between the severity of ischemic right ventricular dysfunction and the necrotic area. The discrepancy may be due to ischemia without necrosis of the right ventricular wall (stunned myocardium), but the intact pericardium and the necrosis of the interventricular septum may also play an important role. In the most severe form of ischemic right ventricular dysfunction, the entire right ventricular wall is akinetic. Right atrial, right ventricular, and pulmonary artery pressures become similar in magnitude and shape, and the pulmonary valve is opened during diastole, demonstrating a passive blood flow from the right atrium to the left ventricle through the low resistance pulmonary capillary bed. Volume loading, administration of dopamine or dobutamine, and careful use of vasodilators under hemodynamic monitoring are the therapeutic measures to control the severe forms of acute ischemic right ventricular dysfunction. The use of thrombolytic agents has decreased the incidence of right ventricular dysfunction after acute myocardial infarction. Mortality is high in the severe forms of acute ischemic right ventricular dysfunction, but after discharge from hospital the prognosis is good and right heart failure is unusual, even in those patients with shock during the first days of evolution of the infarct.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Cohn JN, Guiha M, Broder MI, Limas CJ. Right ventricular infarction. Clinical and hemodynamic features.Am J Cardiol 1974;33:209–214.

    Google Scholar 

  2. Isner J, Roberts WC. Right ventricular infarction complicating left ventricular infarction secondary to coronary heart disease. Frequency, location, associated findings and significance from analysis of 236 necropsy patients with acute or healed myocardial infarction.Am J Cardiol 1978;42:885–894.

    Google Scholar 

  3. Farrer-Brown G. Vascular pattern of myocardium of right ventricle in human heart.Br Heart J 1968;30:697–686.

    Google Scholar 

  4. Dell'Italia LJ, Starling MR, Crawford MH, Boros BL, Chaudhuri TH, O'Rourke RA. Right ventricular infarction: Identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques.J Am Coll Cardiol 1984;4:931–939.

    Google Scholar 

  5. Legrand V, Rigo P, Smeets JP, Demoulin JC, Collignon P, Kulbertus HE. Right ventricular myocardial infarction diagnosed by 99m technetium pyrophosphate scintigraphy: Clinical course and follow-up.Eur Heart J 1983;4:9–19.

    Google Scholar 

  6. Le Leyour J, Daubert JC, Faverau X, Bourdonnec C, Langella B, Gouffault J. Bilan lésionel coronarien des infarctus inféro-postérieurs biventriculaires.Arch Mal Coeur 1986;79:85–93.

    Google Scholar 

  7. Kopelman HA, Forman MB, Wilson BH, et al. Right ventricular myocardial infarction in patients with chronic lung disease: Possible role of right ventricular hypertrophy.J Am Coll Cardiol 1985;5:1302–1307.

    Google Scholar 

  8. Coma-Canella I, Gamallo C, Martínez P, López-Sendón J. Acute right ventricular infarction secondary to massive pulmonary embolism.Eur Heart J 1988;9:534–540.

    Google Scholar 

  9. López-Sendón J, Coma-Canella I, Gamallo C. Sensitivity and specificity of hemodynamic criteria in the diagnosis of acute right ventricular infarction.Circulation 1981;64:515–525.

    Google Scholar 

  10. Haupt HM, Hutchins GM, Moore GW. Right ventricular infarction: Role of the moderator band artery in determining infact size.Circulation 1983;67:1268–1272.

    Google Scholar 

  11. Ratliff NB, Hackel DB. Combined right and left ventricular infarction: Pathogenesis and clinicopathological correlations.Am J Cardiol 1980;45:217–221.

    Google Scholar 

  12. Coma-Canella I, López-Sendón J. Infarto de ventrículo derecho.Rev Esp Cardiol 1979;32:287–298.

    Google Scholar 

  13. Ratliff NB, Peter RH, Ramo BW, Morris JJ. A model for the production of right ventricular infarction.Am J Pathol 1970;58:471–479.

    Google Scholar 

  14. Carlson EB. Right ventricular subendocardial infarction in one patient with pulmonary hypertension, right ventricular hypertrophy and normal coronary arteries.Clin Cardiol 1985;8:499–502.

    Google Scholar 

  15. Erhardt LR. Clinical and pathological observations in different types of acute myocardial infarction. A study of 84 patients deceased after treatment in a coronary care unit.Acta Med Scand 1974;560:1–78.

    Google Scholar 

  16. Coma-Canella I, López-Sendón J, Seoane J, Lombera F, Martín Jadraque L. Evolución y pronóstico del infarto de ventrículo derecho.Rev Esp Cardiol 1983;36:303–308.

    Google Scholar 

  17. Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction.N Engl J Med 1993;328:981–988.

    Google Scholar 

  18. Rigo P, Murray M, Taylor DR, et al. Right ventricular dysfunction detected by scintigraphy in patients with acute inferior myocardial infarction.Circulation 1975;52:268–274.

    Google Scholar 

  19. López-Sendón J, Coma-Canella I, Viñuelas Adanez J. Volume loading in patients with ischemic right ventricular dysfunction.Eur Heart J 1981;2:329–338.

    Google Scholar 

  20. Strasberg B, Pinchas A, Arditti A, et al. Left and right ventricular function in inferior acute myocardial infarction and significance of advanced atrioventricular block.Am J Cardiol 1984;54:985–987.

    Google Scholar 

  21. Daubert JC, Langella B, Besson C, Bourdonnec C, Pony JC, Gouffault J. Etude prospective des critères diagnostiques et prognostiques de l'atteinte ventriculaire droite à la phase aiguë des infarctus inféro-posteriéurs.Arch Mal Coeur 1983;76:991–1003.

    Google Scholar 

  22. Baigrie RS, Haq A, Morgan C, Rakowski H, Drobac M, McLaughlin P. The spectrum of right ventricular involvement in inferior wall myocardial infarction: A clinical, hemodynamic and noninvasive study.J Am Coll Cardiol 1983;1:1396–1340.

    Google Scholar 

  23. Starling MR, Dell'Italia LJ, Chaudhuri TK, Boros BL, O'Rourke RA. First transit and equilibrium radionuclide angiography in patients with inferior transmural myocardial infarction: Criteria for the diagnosis on associated hemodynamically significant right ventricular infarction.J Am Coll Cardiol 1984;4:923–930.

    Google Scholar 

  24. Shah PK, Maddahi J, Berman DS, Pichler M, Swan HJC. Scintigraphically detected predominant right ventricular dysfunction in acute myocardial infarction. Clinical and hemodynamic correlates and implications for therapy and prognosis.J Am Coll Cardiol 1985;6:1264–1272.

    Google Scholar 

  25. Bellamy GR, Rasmussen HH, Nasser FN, Wiseman JC, Cooper RA. Value of two dimensional echocardiography and clinical signs in detecting right ventricular infarction.Am Heart J 1986;112:304–309.

    Google Scholar 

  26. Wartman WB, Hellerstein HK. The incidence of heart disease in 2000 consecutive autopsies.Ann Intern Med 1948;28:41–61.

    Google Scholar 

  27. Pasquali V, de Place C, Mabo P, Bedossa M, Lebreton H, Daubert JC. L'infarctus isole du ventricule driot: Étude clinique et echocardiographique.Ann Cardiol Angeiol 1992;41:69–76.

    Google Scholar 

  28. Daubert JC, Langella B, de Place C. Frequence et prognostic de l'atteinte ventriculaire droite à la phase aigüe de l'infarctus du myocarde.Arch Mal Coeur 1980;73:785–794.

    Google Scholar 

  29. Starr I, Jeffers WA, Meade RH Jr. The absence of conspicuous increments of venous pressure after severe damage to the right ventricle of the dog, with a discussion of the relation between clinical congestive failure and heart disease.Am Heart J 1943;26:291–301.

    Google Scholar 

  30. Hutchins GM, Bilkley BH, Ridolfi RL, Griffith LSC, Lohr FT, Piasio MA. Correlation of coronary arteriograms and left ventriculograms with postmortem studies.Circulation 1977;56:32–37.

    Google Scholar 

  31. Weiss JL, Bulkley BH, Hutchins GM, Mason SJ. Two dimensional echocardiographic recognition of myocardial injury in man. Comparison with postmortem studies.Circulation 1981;63:401–408.

    Google Scholar 

  32. Haines DE, Beller GA, Watson DD, et al. A prospective clinical, scintigraphic, angiographic and functional evaluation of patients after inferior myocardial infarction with and without right ventricular dysfunction.J Am Coll Cardiol 1985;6:995–1003.

    Google Scholar 

  33. Parodi O, Marzullo P, Neglia D, et al. Transient predominant right ventricular ischemia caused by coronary vasospasm.Circulation 1984;70:170–177.

    Google Scholar 

  34. Dell'Italia LJ. The right ventricle. Anatomy, physiology, and clinical importance. In: O'Rourke RA, MacCall D, eds.Current Problems in Cardiology, Vol 26. St. Louis, MO: Mosby-Year Book, 1991:657–720.

    Google Scholar 

  35. Maurer G, Nanda NC. Two dimensional echocardiographic evaluation of exercise induced left and right ventricular asynergy. Correlation with thallium scanning.Am J Cardiol 1981;48:720–727.

    Google Scholar 

  36. Panidis IP, Kotler MN, Mintz GS, et al. Right ventricular function in coronary artery disease assessed by two dimensional echocardiography.Am Heart J 1984;107:1187–1194.

    Google Scholar 

  37. Berger PB, Ruocco NA Jr, Ryan TJ, et al. and the TIMI Research Group. Frequency and significance of right ventricular dysfunction during inferior wall left ventricular myocardial infarction treated with thombolytic therapy.Am J Cardiol 1993;71:1148–1152.

    Google Scholar 

  38. Arditti A, Lewin RF, Hellman C, Sclarowski S, Strasberg B, Agmon J. Right ventricular dysfunction in acute inferior myocardial infarction. An echocardiographic and isotopic study.Chest 1985;87:307–314.

    Google Scholar 

  39. Lorell B, Leinbach RC, Pohost GM, et al. Right ventricular infarction. Clinical diagnosis and differentiation from pericardial tamponade and pericardial constriction.Am J Cardiol 1979;43:465–471.

    Google Scholar 

  40. Urrengoetxea J, Zeitún M, Aguirre JM, et al. Evaluación a largo plazo de la función mecánica en el infarto de ventrículo derecho. In: Iriarte M, Sagastagoitia JD, eds.Insuficiencia Cardiaca Crónica. Barcelona: Editorial MCR, 1989:225–237.

    Google Scholar 

  41. López-Sendón J, García-Fernandez MA, Coma-Canella I, Moreno Yangüela M, Bañuelos F. Segmental right ventricular function after acute myocardial infarction. Two dimensional echocardiographic study in 63 patients.Am J Cardiol 1983;51:390–396.

    Google Scholar 

  42. García-Fernandez MA, López-Sendón J, Moreno Yangüela M. Two dimensional echocardiography and Doppler findings in right ventricular infarction. In: Iliceto S, Rizzon P, Roelandt JRTC, eds.Ultrasound in Coronary Artery Disease. Boston: Kluwer Academic Publishers, 1991:151–181.

    Google Scholar 

  43. Jugdutt BI, Sussex BA, Sivaram CA, Rosall RE. Right ventricular infarction. Two dimensional echocardiographic evaluation.Am Heart J 1984;107:505–518.

    Google Scholar 

  44. Koito H, Kurimoto T, Sugiura T, et al. Right ventricular function in patients with chronic right ventricular infarction.J Cardiol 1987;17:13–20.

    Google Scholar 

  45. Vannuci A, Cecchi F, Zuppiroli A, et al. Right ventricular infarction: Clinical, hemodynamic, mono and 2D echocardiographic features.Eur Heart J 1983;4:854–864.

    Google Scholar 

  46. Kaul S, Hopkins JM, Shah PM. Chronic effects of myocardial infarction on right ventricular function: A noninvasive assessment.J Am Coll Cardiol 1983;2:607–615.

    Google Scholar 

  47. López-Sendón J, Coma-Canella I, Lombera F, Benito Bartolomé F. Diagnosis of ischemic right ventricular dysfunction by M mode echocardiography.Eur Heart J 1982;3:230–237.

    Google Scholar 

  48. Descaves C, Daubert JC, Langella B, Bourdonnec C, Pony JC, Gouffault J. Devenir à moyen terme de la dysfonction aigüe du ventricle droit dans les infarctus du myocarde biventriculaires. Etude hémodynamique et cinéangiographique.Arch Mal Coeur 1987;80:1268–1277.

    Google Scholar 

  49. Ratner SJ, Huang PJ, Friedman MI, Pierson RN Jr. Assessment of right ventricular anatomy and function by quantitative radionuclide ventriculography.J Am Coll Cardiol 1989;13:354–359.

    Google Scholar 

  50. García-Fernandez MA, Höpez-Sendón J, Moreno Yangüela M, Martín Jadraque L, Bañuelos F. Aneurisma de ventrículo derecho. Presentación de un caso diagnosticado mediante ecocardiografía bidimensional.Rev Esp Cardiol 1983;36:255–257.

    Google Scholar 

  51. Coma-Canella I, López-Sendón J. Ventricular compliance in ischemic right ventricular dysfunction.Am J Cardiol 1980;45:555–561.

    Google Scholar 

  52. Butman S, Olson HG, Aronow WS, Lyons KP. Remote right ventricular myocardial infarction mimicking chronic pericardial constriction.Am Heart J 1982;103:912–914.

    Google Scholar 

  53. Lorente P, Delabreé M, Masquet C, Gourgon R. A statistical prognostic study of pump failure in acute myocardial infarction.Cardiovasc Res 1975;9:420–432.

    Google Scholar 

  54. Coma-Canella I, Etayo A, López-Sendón J, Calderón Montero J. Diagnóstico diferencial del infarto de ventrículo derecho.Rev Esp Cardiol 1982;35:499–506.

    Google Scholar 

  55. López-Sendón J, González A, López de Sá E, et al. Diagnosis of subacute ventricular wall rupture after acute myocardial infarction: Sensitivity and specificity of clinical, hemodynamic and echocardiographic criteria.J Am Coll Cardiol 1992;19:1145–1153.

    Google Scholar 

  56. Coma-Canella I, López-Sendón J, Gamallo C. Low output syndrome in right ventricular infarction.Am Heart J 1979;98:613.

    Google Scholar 

  57. López-Sendón J, Coma-Canella I, Viñuelas Adanez J. Volume loading in patients with ischemic right ventricular dysfunction.Eur Heart J 1981;2:329–338.

    Google Scholar 

  58. Guntheroth WG, Jacky JP. The effect of respiration on venous return and pleural and pericardial pressure. In:Pericardial Disease. Reddy PS, Leon DF, Shaver JA, eds. New York: Raven Press, 1982:137–147.

    Google Scholar 

  59. Shabetai R.The Pericardium. New York: Grune and Stratton, 1981:154–223.

    Google Scholar 

  60. López-Sendón J, Coma-Canella I, Martín Jadraque L, González Maqueda I. Pulmonary pulsus alternans in acute myocardial infarction.Am J Cardiol 1978;42:577–582.

    Google Scholar 

  61. Kaul S. The interventricular septum in health and disease.Am Heart J 1986;112:568–581.

    Google Scholar 

  62. Lima JA, Guzman PA, Yin FCP, et al. Septal geometry in the unloaded living human heart.Circulation 1986;74:463–468.

    Google Scholar 

  63. Sharkey SW. M-mode and 2D echo analysis of the septum in experimental right ventricular infarction: Correlation with hemodynamic alterations.Am Heart J 1985;110:1210–1218.

    Google Scholar 

  64. Kingma I, Tyberg JV, Smith ER. Effects of diastolic transeptal pressure gradient on ventricular septal position and motion.Circulation 1983;68:1304–1214.

    Google Scholar 

  65. López-Sendón J, López de Sá E, Roldán I, Fernández de Soria R, Ramos F, Martín Jadraque L. Inversion of the normal interatrial septum convexity in acute myocardial infarction: Incidence, clinical relevance and prognostic significance.J Am Coll Cardiol 1990;15:801–805.

    Google Scholar 

  66. Agata Y. Two-dimensional echocardiographic determinants of interventricular septal configuration in right or left ventricular overload.Am Heart J 1985;110:819–825.

    Google Scholar 

  67. Feneley M, Gavaghan T. Paradoxical and pseudoparadoxical interventricular septal motion in patients with right ventricular volume overload.Circulation 1986;74:230–238.

    Google Scholar 

  68. Vinuelas J, López-Sendón J, Lombera F, Coma-Canella I, Martín Jadraque L. Distensibilidad del ventrículo derecho en el infarto agudo de miocardio inferior. Estudio de las variaciones de la presión auricular derecha mediante la administración de líquidos.Rev Esp Cardiol 1982;35:507–510.

    Google Scholar 

  69. Isner JM. Right ventricular myocardial infarction. In:The Right Ventricle. Konstman MA, Isner JM, eds. Dordrecht: Kluwer Academic, 1988:87–129.

    Google Scholar 

  70. Shabetai R. Pericardial influences on the right heart. In:The Right Ventricle. Konstman MA, Isner JM, eds. Dordrecht: Kluwer Academic, 1988:53–70.

    Google Scholar 

  71. Goldstein JA, Vlahakes GJ, Verrier ED, et al. The role of right ventricular systolic dysfunction and elevated intrapericardial pressure in the genesis of low ouput in experimental right ventricular infarction.Circulation 1982:65:513–522.

    Google Scholar 

  72. Coma-Canella I, López-Sendón J, Lombera F, Silvestre J, García-Fernandez MA. Hemodynamic findings in experimental right ventricular ischemia after right coronary artery ligation.Eur Heart J 1986;7:711–719.

    Google Scholar 

  73. Goldstein JA, Barzilai B, Rosamond TL, Eisenberg PR, Jaffe AS. Determinants of hemodynamic compromise with severe right ventricular infarction.Circulation 1990;82:359–364.

    Google Scholar 

  74. Refsum H, Junemann M, Lipton MJ, Skioldebrand C, Carlson E, Tyberg JV. Ventricular diastolic pressure-volume relations and the pericardium. Effects of changes in blood volume and pericardial effusion in dogs.Circulation 1981;64:997–1004.

    Google Scholar 

  75. Coma-Canella I, López-Sendón J, Nuñez González L, Ferrufino O. Subacute left ventricular free wall rupture following acute myocardial infarction: Bedside hemodynamics, differential diagnosis and treatment.Am Heart J 1983;106:278–284.

    Google Scholar 

  76. Benito F, López-Sendón J, Oliver J, García-Fernandez MA, Coma-Canella I, Lombera F. Echocardiographic premature pulmonic valve opening: Sign of reduced right ventricular distensibility.Am Heart J 1984;107:1029–1023.

    Google Scholar 

  77. López-Sendón J, Gonzalez García A, Sotillo Martí J, Roldan I. Complete pulmonic valve opening during atrial contraction after right ventricular infarction.Am J Cardiol 1985;56:486–487.

    Google Scholar 

  78. Topol EJ, Goldschlager N, Ports TA. Hemodynamic benefit of atrial pacing in right ventricular myocardial infarction.Ann Intern Med 1982;96:594–597.

    Google Scholar 

  79. Berisha S, Kastrati A, Goda A, Popa Y. Optimal value of filling pressure in the right side of the heart in acute right ventricular infarction.Br Heart J 1990;63:98–102.

    Google Scholar 

  80. Kalan JM, Gertz SD, Kragel AH, Berger PB, Roberts WC, Ryan TJ. Effects of tissue plasminogen activator therapy on the frequency of acute right ventricular myocardial infarction associated with acute left ventricular infarction.Int J Cardiol 1993;38:151–158.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Cardiology Department, Hospital “Gregorio Marañón” Madrid, Universidad Complutense de Madrid, Madrid, Spain

    José López-Sendón, Esteban López de Sá & Juán Luís Delcán

Authors
  1. José López-Sendón
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Esteban López de Sá
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Juán Luís Delcán
    View author publications

    You can also search for this author in PubMed Google Scholar

Additional information

Address for correspondence: Coronary Care Unit, Cardiology Department, Hospital Gregorio Marañón, % Dr. Esquerdo 46, 28007 Madrid, Spain.

Rights and permissions

Reprints and permissions

About this article

Cite this article

López-Sendón, J., López de Sá, E. & Delcán, J.L. Ischemic right ventricular dysfunction. Cardiovasc Drug Ther 8 (Suppl 2), 393–406 (1994). https://doi.org/10.1007/BF00877324

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF00877324

Key words

Search

Navigation