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Perioperative right ventricular function and dysfunction in adult cardiac surgery—focused review (part 1—anatomy, pathophysiology, and diagnosis)

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Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Right ventricle (RV) dysfunction and failure are now increasingly recognized as an important cause of perioperative morbidity and mortality after cardiac surgery. Although RV dysfunction is common, RV failure is very rare (0.1%) after routine cardiac surgery. However, it occurs in 3% of patients after heart transplantation and in up to 30% of patients after left ventricular assist device implantation. Significant RV failure after cardiac surgery has high mortality. Knowledge of RV anatomy and physiology are important for understanding RV dysfunction and failure. Echocardiography and haemodynamic monitoring are the mainstays in the diagnosis of RV dysfunction and failure. While detailed echocardiography assessment of right heart function has been extensively studied and validated in the elective setting, gross estimation of RV chamber size, function, and some easily obtained quantitative parameters on transesophageal echocardiography are useful in the perioperative setting. However, detailed knowledge of echocardiography parameters is still useful in understanding the differences in contractile pattern, ventriculo-arterial coupling, and interventricular dependence that ensue after open cardiac surgery.

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Authors and Affiliations

  1. Divisions of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India

    Praveen Kerala Varma, Neethu Krishna & Balaji Srimurugan

  2. Divisions of Cardiac Anesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India

    Reshmi Liza Jose & Aveek Jayant

  3. Division of Cardiac Surgery, Rajagiri Hospital, Kochi, India

    George Jose Valooran

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  1. Praveen Kerala Varma
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Transesophageal echocardiography 4 chamber view showing normal right ventricular movements. Majority of systolic function occurs by longitudinal contraction supplemented by inward movement of free wall. Additional ejection of right ventricle is contributed by bulging of Inter-ventricular septum to right. (WMV 1609 KB)

Severe right ventricular pressure load causing D shaped septum. The patient is a post operative case of Pulmonary Thromboendarterectomy. The right ventricular pressure was supra-systemic. (WMV 2009 KB)

Transesophageal echocardiography mid esophageal 4 chamber view showing Inter-ventricular septum flopping back and forth. This is typically seen in volume overloaded right ventricle (WMV 1969 KB)

Mid-esophageal 4 chamber view showing poor right ventricular contraction with right ventricular dilatation. Right ventricular size is almost similar to that of left ventricle. Right ventricular dilatation also causes stretching of tricuspid annulus leading to severe tricuspid valve regurgitation. (WMV 1270 KB)

This patient underwent aortic valve replacement with tricuspid valve annuloplasty for bicuspid aortic valve stenosis with severe left ventricular dysfunction and congestive heart failure with mild right ventricular dysfunction. After tricuspid valve annuloplasty the longitudinal movement of tricuspid annulus is restricted and tricuspid annular plane excursion was low. Fractional area change is a more reliable indicator of right ventricular function in these settings. (WMV 1270 KB)

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Varma, P.K., Jose, R.L., Krishna, N. et al. Perioperative right ventricular function and dysfunction in adult cardiac surgery—focused review (part 1—anatomy, pathophysiology, and diagnosis). Indian J Thorac Cardiovasc Surg 38, 45–57 (2022). https://doi.org/10.1007/s12055-021-01240-y

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