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Right-sided heart failure: Diagnosis and treatment strategies

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Right ventricular (RV) dysfunction in the setting of cardiomyopathy, ischemia, and pulmonary hypertension is associated with high morbidity and mortality, but therapeutic clinical trials examining RV failure as a primary outcome are lacking. This review focuses on the ontologic, morphologic, and microscopic differences between the right and left ventricles. It also discusses the rationale and potential risks associated with the extrapolation of medical therapies used in left ventricular failure and pulmonary arterial hypertension management to the treatment of RV failure. Finally, it introduces the reader to new echocardiographic techniques that may be used to diagnose clinical and subclinical RV systolic and diastolic dysfunction. Given the anticipated rise in the prevalence of RV dysfunction, more studies are needed to gain a better understanding of RV cellular and subcellular function and its response to pathologic stressors and disease so that therapeutic targets can be devised to improve RV failure morbidity and mortality.

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References and Recommended Reading

  1. Chockalingam A, Gnanavelu G, Subramaniam T, et al.: Right ventricular myocardial infarction: presentation and acute outcomes. Angiology 2005, 56:371–376.

    Article  PubMed  Google Scholar 

  2. Benedict N, Seybert A, Mathier MA: Evidence-based pharmacologic management of pulmonary arterial hypertension. Clin Ther 2007, 29:2134–2153.

    Article  CAS  PubMed  Google Scholar 

  3. Srivastava D: Making or breaking the heart: from lineage determination to morphogenesis. Cell 2006, 126:1037–1048.

    Article  CAS  PubMed  Google Scholar 

  4. Snarr BS, O’Neal JL, Chintalapudi MR, et al.: Isl1 expression at the venous pole identifies a novel role for the second heart field in cardiac development. Circ Res 2007, 101:971–974.

    Article  CAS  PubMed  Google Scholar 

  5. Buckingham M, Meilhac S, Zaffran S: Building the mammalian heart from two sources of myocardial cells. Nat Rev Genet 2005, 6:826–835.

    Article  CAS  PubMed  Google Scholar 

  6. Cai CL, Liang X, Shi Y, et al.: Isl1 identifies a cardiac progenitor population that proliferates prior to differentiation and contributes a majority of cells to the heart. Dev Cell 2003, 5:877–889.

    Article  CAS  PubMed  Google Scholar 

  7. Chin KM, Kim NH, Rubin LJ: The right ventricle in pulmonary hypertension. Coron Artery Dis 2005, 16:13–18.

    Article  PubMed  Google Scholar 

  8. Mebazaa A, Karpati P, Renaud E, Algotsson L: Acute right ventricular failure—from pathophysiology to new treatments. Intensive Care Med 2004, 30:185–196.

    Article  PubMed  Google Scholar 

  9. Kondo RP: Comparison of contraction and calcium handling between right and left ventricular myocytes from adult mouse heart: a role for repolarization waveform. J Physiol 2006, 571:131.

    Article  CAS  PubMed  Google Scholar 

  10. Wang GY, McCloskey DT, Turcato S, et al.: Contrasting inotropic responses to alpha1-adrenergic receptor stimulation in left versus right ventricular myocardium. Am J Physiol Heart Circ Physiol 2006, 291:H2013–H2017.

    Article  CAS  PubMed  Google Scholar 

  11. Markel TA, Crisostomo PR, Wang M, et al.: Right ventricular TNF resistance during endotoxemia: the differential effects on ventricular function. Am J Physiol Regul Integr Comp Physiol 2007, 293:R1893–R1897.

    CAS  PubMed  Google Scholar 

  12. Ganguly PK, Dhalla KS, Shao Q, et al.: Differential changes in sympathetic activity in left and right ventricles in congestive heart failure after myocardial infarction. Am Heart J 1997, 133:340–345.

    Article  CAS  PubMed  Google Scholar 

  13. Sethi R, Dhalla KS, Beamish RE, Dhalla NS: Differential changes in left and right ventricular adenylyl cyclase activities in congestive heart failure. Am J Physiol 1997, 272:H884–H893.

    CAS  PubMed  Google Scholar 

  14. Atkins FL, Bing OH, DiMauro PG, et al.: Modulation of left and right ventricular beta-adrenergic receptors from spontaneously hypertensive rats with left ventricular hypertrophy and failure. Hypertension 1995, 26:78–82.

    CAS  PubMed  Google Scholar 

  15. Afzal N, Dhalla NS: Differential changes in left and right ventricular SR calcium transport in congestive heart failure. Am J Physiol 1992, 262:H868–H874.

    CAS  PubMed  Google Scholar 

  16. Takahashi M, Tanonaka K, Yoshida H, et al.: Effects of angiotensin I-converting enzyme inhibitor and angiotensin II type 1 receptor blocker on the right ventricular sarcoglycans and dystrophin after left coronary artery ligation. Eur J Pharmacol 2005, 522:84–93.

    Article  CAS  PubMed  Google Scholar 

  17. Faludi R, Komocsi A, Bozo J, et al.: Isolated diastolic dysfunction of right ventricle: stress-induced pulmonary hypertension. Eur Respir J 2008, 31:475–476.

    Article  CAS  PubMed  Google Scholar 

  18. Dursunoglu N, Dursunoglu D, Kilic M: Impact of obstructive sleep apnea on right ventricular global function: sleep apnea and myocardial performance index. Respiration 2005, 72:278–284.

    Article  PubMed  Google Scholar 

  19. Sun XG, Hansen JE, Oudiz RJ, Wasserman K: Exercise pathophysiology in patients with primary pulmonary hypertension. Circulation 2001, 104:429–435.

    Article  CAS  PubMed  Google Scholar 

  20. Chockalingam A: Myocardial performance index in evaluation of acute right ventricular myocardial infarction. Echocardiography 2004, 21:487–494.

    Article  PubMed  Google Scholar 

  21. Meluzin J, Spinarova L, Hude P, et al.: Prognostic importance of various echocardiographic right ventricular functional parameters in patients with symptomatic heart failure. J Am Soc Echocardiogr 2005, 18:435–444.

    Article  PubMed  Google Scholar 

  22. Møller JE, Sondergaard E, Poulsen SH, et al.: Serial Doppler echocardiographic assessment of left and right ventricular performance after a first myocardial infarction. J Am Soc Echocardiogr 2001, 14:249–255.

    Article  PubMed  Google Scholar 

  23. Romero-Corral A, Somers VK, Pellikka PA, et al.: Decreased right and left ventricular myocardial performance in obstructive sleep apnea. Chest 2007, 132:1863–1870.

    Article  PubMed  Google Scholar 

  24. Gondi S, Dokainish H: Right ventricular tissue Doppler and strain imaging: ready for clinical use? Echocardiography 2007, 24:522–532.

    Article  PubMed  Google Scholar 

  25. Wong CY, O’Moore-Sullivan T, Leano R, et al.: Association of subclinical right ventricular dysfunction with obesity. J Am Coll Cardiol 2006, 47:611–616.

    Article  PubMed  Google Scholar 

  26. Meluzin J, Spinarova L, Dusek L, et al.: Prognostic importance of the right ventricular function assessed by Doppler tissue imaging. Eur J Echocardiogr 2003, 4:262–271.

    Article  CAS  PubMed  Google Scholar 

  27. Spinarova L, Meluzin J, Toman J, et al.: Right ventricular dysfunction in chronic heart failure patients. Eur J Heart Fail 2005, 7:485–489.

    Article  PubMed  Google Scholar 

  28. Kanzaki H, Nakatani S, Kawada T, et al.: Right ventricular dP/dt/P(max), not dP/dt(max), noninvasively derived from tricuspid regurgitation velocity is a useful index of right ventricular contractility. J Am Soc Echocardiogr 2002, 15:136–142.

    Article  PubMed  Google Scholar 

  29. Hunt SA: ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2005, 46:e1–e82.

    Article  PubMed  Google Scholar 

  30. Voelkel NF, Quaife RA, Leinwand LA, et al.: Right ventricular function and failure: report of a National Heart, Lung, and Blood Institute working group on cellular and molecular mechanisms of right heart failure. Circulation 2006, 114:1883–1891.

    Article  PubMed  Google Scholar 

  31. Cowburn PJ, Cleland JG, McDonagh TA, et al.: Comparison of selective ET(A) and ET(B) receptor antagonists in patients with chronic heart failure. Eur J Heart Fail 2005, 7:37–42.

    Article  CAS  PubMed  Google Scholar 

  32. Attina T, Camidge R, Newby DE, Webb DJ: Endothelin antagonism in pulmonary hypertension, heart failure, and beyond. Heart 2005, 91:825–831.

    Article  CAS  PubMed  Google Scholar 

  33. Nootens M, Kaufmann E, Rector T, et al.: Neurohormonal activation in patients with right ventricular failure from pulmonary hypertension: relation to hemodynamic variables and endothelin levels. J Am Coll Cardiol 1995, 26:1581–1585.

    Article  CAS  PubMed  Google Scholar 

  34. Matthews JC, McLaughlin VV: Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: a detailed review of the pathophysiology, diagnosis, and management. Curr Cardiol Rev 2008, 4:49–59.

    Article  PubMed  Google Scholar 

  35. Humbert M, Barst RJ, Robbins IM, et al.: Combination of bosentan with epoprostenol in pulmonary arterial hypertension: BREATHE-2. Eur Respir J 2004, 24:353–359.

    Article  CAS  PubMed  Google Scholar 

  36. Channick RN, Simonneau G, Sitbon O, et al.: Effects of the dual endothelin-receptor antagonist bosentan in patients with pulmonary hypertension: a randomised placebo-controlled study. Lancet 2001, 358:1119–1123.

    Article  CAS  PubMed  Google Scholar 

  37. Coletta AP, Clark AL, Seymour AM, Cleland JG: Clinical trials update from the European Society of Cardiology Heart Failure meeting: COMET, COMPANION, Tezosentan and SHAPE. Eur J Heart Fail 2003, 5:545–548.

    Article  PubMed  Google Scholar 

  38. Kaluski E, Kobrin I, Zimlichman R, et al.: RITZ-5: randomized intravenous TeZosentan (an endothelin-A/B antagonist) for the treatment of pulmonary edema: a prospective, multicenter, double-blind, placebo-controlled study. J Am Coll Cardiol 2003, 41:204–210.

    Article  CAS  PubMed  Google Scholar 

  39. McMurray JJ, Teerlink JR, Cotter G, et al.: Effects of tezosentan on symptoms and clinical outcomes in patients with acute heart failure: the VERITAS randomized controlled trials. JAMA 2007, 298:2009–2019.

    Article  CAS  PubMed  Google Scholar 

  40. Kelland NF, Webb DJ: Clinical trials of endothelin antagonists in heart failure: publication is good for the public health. Heart 2007, 93:2–4.

    Article  CAS  PubMed  Google Scholar 

  41. Louis A, Cleland JG, Crabbe S, et al.: Clinical trials update: CAPRICORN, COPERNICUS, MIRACLE, STAF, RITZ-2, RECOVER and RENAISSANCE and cachexia and cholesterol in heart failure. Highlights of the Scientific Sessions of the American College of Cardiology, 2001. Eur J Heart Fail 2001; 3:381–387.

    Article  CAS  PubMed  Google Scholar 

  42. Coletta AP, Cleland JG: Clinical trials update: highlights of the scientific sessions of the XXIII Congress of the European Society of Cardiology—WARIS II, ESCAMI, PAFAC, RITZ-1 and TIME. Eur J Heart Fail 2001, 3:747–750.

    Article  CAS  PubMed  Google Scholar 

  43. Leslie SJ, Spratt JC, McKee SP, et al.: Direct comparison of selective endothelin A and non-selective endothelin A/B receptor blockade in chronic heart failure. Heart 2005, 91:914–919.

    Article  CAS  PubMed  Google Scholar 

  44. Wittbrodt ET, Abubakar A: Sitaxsentan for treatment of pulmonary hypertension. Ann Pharmacother 2007, 41:100–105.

    CAS  PubMed  Google Scholar 

  45. Souza R, Martins BC, Jardim C, et al.: Effect of sitaxsentan treatment on quality of life in pulmonary arterial hypertension. Int J Clin Pract 2007, 61:153–156.

    Article  CAS  PubMed  Google Scholar 

  46. Anand I, McMurray J, Cohn JN, et al.: Long-term effects of darusentan on left-ventricular remodelling and clinical outcomes in the EndothelinA Receptor Antagonist Trial in Heart Failure (EARTH): randomised, double-blind, placebo-controlled trial. Lancet 2004, 364:347–354.

    Article  CAS  PubMed  Google Scholar 

  47. Kelland NF, Webb DJ: Clinical trials of endothelin antagonists in heart failure: a question of dose? Exp Biol Med (Maywood) 2006, 231:696–699.

    CAS  Google Scholar 

  48. Costard-Jackle A, Fowler MB: Influence of preoperative pulmonary artery pressure on mortality after heart transplantation: testing of potential reversibility of pulmonary hypertension with nitroprusside is useful in defining a high risk group. J Am Coll Cardiol 1992, 19:48–54.

    Article  CAS  PubMed  Google Scholar 

  49. Mogollon MV, Lage E, Cabezon S, et al.: Combination therapy with sildenafil and bosentan reverts severe pulmonary hypertension and allows heart transplantation: case report. Transplant Proc 2006, 38:2522–2523.

    Article  CAS  PubMed  Google Scholar 

  50. Cuffe MS, Califf RM, Adams KF Jr, et al.: Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA 2002, 287:1541–1547.

    Article  CAS  PubMed  Google Scholar 

  51. Packer M, Carver JR, Rodeheffer RJ, et al.: Effect of oral milrinone on mortality in severe chronic heart failure. The PROMISE Study Research Group. N Engl J Med 1991, 325:1468–1475.

    CAS  PubMed  Google Scholar 

  52. Patel MD, Katz SD: Phosphodiesterase 5 inhibition in chronic heart failure and pulmonary hypertension. Am J Cardiol 2005, 96:47M–51M.

    Article  CAS  PubMed  Google Scholar 

  53. Lewis GD, Lachmann J, Camuso J, et al.: Sildenafil improves exercise hemodynamics and oxygen uptake in patients with systolic heart failure. Circulation 2007, 115:59–66.

    Article  CAS  PubMed  Google Scholar 

  54. Lewis GD, Shah R, Shahzad K, et al.: Sildenafil improves exercise capacity and quality of life in patients with systolic heart failure and secondary pulmonary hypertension. Circulation 2007, 116:1555–1562.

    Article  CAS  PubMed  Google Scholar 

  55. Guazzi M, Samaja M, Arena R, et al.: Long-term use of sildenafil in the therapeutic management of heart failure. J Am Coll Cardiol 2007, 50:2136–2144.

    Article  CAS  PubMed  Google Scholar 

  56. Gandolfo C, Sugo A, Del Sette M: Sildenafil and transient global amnesia. Neurol Sci 2003, 24:145–146.

    Article  CAS  PubMed  Google Scholar 

  57. Pomeranz HD, Bhavsar AR: Nonarteritic ischemic optic neuropathy developing soon after use of sildenafil (Viagra): a report of seven new cases. J Neuroophthalmol 2005, 25:9–13.

    PubMed  Google Scholar 

  58. Zakliczynski M, Maruszewski M, Pyka L, et al.: Effectiveness and safety of treatment with sildenafil for secondary pulmonary hypertension in heart transplant candidates. Transplant Proc 2007, 39:2856–2858.

    Article  CAS  PubMed  Google Scholar 

  59. Jabbour A, Keogh A, Hayward C, Macdonald P: Chronic sildenafil lowers transpulmonary gradient and improves cardiac output allowing successful heart transplantation. Eur J Heart Fail 2007, 9:674–677.

    Article  CAS  PubMed  Google Scholar 

  60. Bradley TD, Floras JS: Sleep apnea and heart failure: part I: obstructive sleep apnea. Circulation 2003, 107:1671–1678.

    Article  PubMed  Google Scholar 

  61. Bradley TD, Floras JS: Sleep apnea and heart failure: part II: central sleep apnea. Circulation 2003, 107:1822–1826.

    Article  PubMed  Google Scholar 

  62. Arzt M, Bradley TD: Treatment of sleep apnea in heart failure. Am J Respir Crit Care Med 2006, 173:1300–1308.

    Article  PubMed  Google Scholar 

  63. Chwan Ng AC, Freedman SB, Sindone AP: Autonomic abnormalities in congestive heart failure patients with sleep-disordered breathing. J Card Fail 2007, 13:395–400.

    Article  PubMed  Google Scholar 

  64. Golbin JM, Somers VK, Caples SM: Obstructive sleep apnea, cardiovascular disease, and pulmonary hypertension. Proc Am Thorac Soc 2008, 5:200–206.

    Article  PubMed  Google Scholar 

  65. Shahar E, Whitney CW, Redline S, et al.: Sleep-disordered breathing and cardiovascular disease cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001, 163:19–25.

    CAS  PubMed  Google Scholar 

  66. Oldenburg O, Lamp B, Faber L, et al.: Sleep-disordered breathing in patients with symptomatic heart failure: a contemporary study of prevalence in and characteristics of 700 patients. Eur J Heart Fail 2007, 9:251–257.

    Article  PubMed  Google Scholar 

  67. Schulz R, Blau A, Borgel J, et al.: Sleep apnoea in heart failure. Eur Respir J 2007, 29:1201–1205.

    Article  CAS  PubMed  Google Scholar 

  68. Otto ME, Belohlavek M, Romero-Corral A, et al.: Comparison of cardiac structural and functional changes in obese otherwise healthy adults with versus without obstructive sleep apnea. Am J Cardiol 2007, 99:1298–1302.

    Article  PubMed  Google Scholar 

  69. Guidry UC, Mendes LA, Evans JC, et al.: Echocardiographic features of the right heart in sleep-disordered breathing: the Framingham Heart Study. Am J Respir Crit Care Med 2001, 164:933–938.

    CAS  PubMed  Google Scholar 

  70. Kessler R, Chaouat A, Weitzenblum E, et al.: Pulmonary hypertension in the obstructive sleep apnoea syndrome: prevalence, causes and therapeutic consequences. Eur Resp J 1996, 9:787–794.

    Article  CAS  Google Scholar 

  71. Arias MA, Garcia-Rio F, Alonso-Fernandez A, et al.: Pulmonary hypertension in obstructive sleep apnoea: effects of continuous positive airway pressure: a randomized, controlled cross-over study. Eur Heart J 2006, 27:1106–1113.

    Article  PubMed  Google Scholar 

  72. Sajkov D, Wang T, Saunders NA, et al.: Continuous positive airway pressure treatment improves pulmonary hemodynamics in patients with obstructive sleep apnea. Am J Respir Crit Care Med 2002, 165:152–158.

    PubMed  Google Scholar 

  73. Wang H, Parker JD, Newton GE, et al.: Influence of obstructive sleep apnea on mortality in patients with heart failure. J Am Coll Cardiol 2007, 49:1625–1631.

    Article  PubMed  Google Scholar 

  74. Young T, Skatrud J, Peppard PE: Risk factors for obstructive sleep apnea in adults. JAMA 2004, 291:2013–2016.

    Article  CAS  PubMed  Google Scholar 

  75. Naughton MT, Benard DC, Liu PP, et al.: Effects of nasal CPAP on sympathetic activity in patients with heart failure and central sleep apnea. Am J Respir Crit Care Med 1995, 152:473–479.

    CAS  PubMed  Google Scholar 

  76. Mansfield D, Kaye DM, Brunner La Rocca H, et al.: Raised sympathetic nerve activity in heart failure and central sleep apnea is due to heart failure severity. Circulation 2003, 107:1396–1400.

    Article  PubMed  Google Scholar 

  77. Gilman MP, Floras JS, Usui K, et al.: Continuous positive airway pressure increases heart rate variability in heart failure patients with obstructive sleep apnoea. Clin Sci (Lond) 2008, 114:243–249.

    Article  Google Scholar 

  78. Solin P, Bergin P, Richardson M, et al.: Influence of pulmonary capillary wedge pressure on central apnea in heart failure. Circulation 1999, 99:1574–1579.

    CAS  PubMed  Google Scholar 

  79. Snow JB, Kitzis V, Norton CE, et al.: Differential effects of chronic hypoxia and intermittent hypocapnic and eucapnic hypoxia on pulmonary vasoreactivity. J Appl Physiol 2008, 104:110–118.

    Article  CAS  PubMed  Google Scholar 

  80. Arzt M, Floras JS, Logan AG, et al.: Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure: a post hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients With Central Sleep Apnea and Heart Failure Trial (CANPAP). Circulation 2007, 115:3173–3180.

    Article  PubMed  Google Scholar 

  81. Matthews JC, Pagani FD, Aaronson KD: Right ventricular failure risk score: a preoperative prediction tool for assessing the risk of right ventricular failure in left ventricular assist device candidates. J Am Coll Cardiol 2008 (in press).

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Authors and Affiliations

  1. Department of Internal Medicine, Division of Cardiovascular Medicine, Heart Failure, and Cardiac Transplant, University of Michigan Health System, 1500 East Medical Center Drive, SPC 5853, Ann Arbor, MI, 48109, USA

    Jennifer Cowger Matthews

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  1. Jennifer Cowger Matthews
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  2. Todd F. Dardas
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  3. Michael P. Dorsch
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  4. Keith D. Aaronson
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Correspondence to Jennifer Cowger Matthews.

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Matthews, J.C., Dardas, T.F., Dorsch, M.P. et al. Right-sided heart failure: Diagnosis and treatment strategies. Curr Treat Options Cardiovasc Med 10, 329–341 (2008). https://doi.org/10.1007/s11936-008-0053-6

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