Elsevier

International Journal of Cardiology

Volume 221, 15 October 2016, Pages 1132-1142
International Journal of Cardiology

Review
Echocardiographic assessment of the right ventricle: Impact of the distinctly load dependency of its size, geometry and performance

https://doi.org/10.1016/j.ijcard.2016.07.014Get rights and content

Highlights

  • Right ventricle (RV) assessment in relation to load enhances estimation of RV function.

  • Echo-variables which integrate contraction and load improve assessment of RV function.

  • The echo-derived “RV load adaptation index” predicts reversibility of RV dysfunction.

  • RV evaluation in relation to load is useful before ventricular assist device implantation.

  • RV evaluation in relation to load improves patient listing for lung transplantation.

Abstract

Right ventricular (RV) size, shape and function are distinctly load-dependent and pulmonary load is an important determinant of RV function in patients with congestive heart failure (CHF) due to primary impaired left ventricular function and in those with pre-capillary pulmonary hypertension (PH). In a pressure overloaded RV, not only dilation and aggravation of tricuspid regurgitation, but also systolic dysfunction leading to RV failure (RVF) can occur already before the development of irreversible alterations in RV myocardial contractility. This explains RV ability for reverse remodeling and functional improvement in patients with post-capillary and pre-capillary PH of a different etiology, after normalization of loading conditions.

There is increasing evidence that RV evaluation by echocardiography in relation with its loading conditions can improve the decision-making process and prognosis assessments in clinical praxis. Recent approaches to evaluate the RV in relation with its actual loading conditions by echo-derived composite variables which either incorporate a certain functional parameter (i.e. tricuspid annulus peak systolic excursion, stroke volume, RV end-systolic volume index, velocity of myocardial shortening) and load, or incorporate measures which reflect the relationship between RV load and RV dilation, also taking the right atrial pressure into account (i.e. “load adaptation index”), appeared particularly suited and therefore also potentially useful for evaluation of RV contractile function. Special attention is focused on the usefulness of RV echo-evaluation in relation to load for proper decision making before ventricular assist-device implantation in patients with CHF and for optimal timing of listing procedures to transplantation in patients with end-stage pre-capillary PH.

Introduction

Right ventricular (RV) performance is a reflection of contractility, preload and afterload, also being influenced by valvular function, heart rhythm, ventricular interdependence and synchrony of ventricular contraction. Acting more as a volume pump, the RV tolerates less pressure overload than volume overload and has higher sensitivity to afterload changes than the left ventricle (LV). Thus, RV performance is distinctly afterload-dependent and both reduction in systolic function and ventricular enlargement occur much earlier in the pressure overloaded RV than in the pressure overloaded LV [1], [2].

Pulmonary load is an important determinant of RV function in patients with congestive heart failure (CHF) due to primary impaired LV function and in those with pre-capillary pulmonary hypertension (PH). Indeed, the most common causes of RV failure (RVF) are left-sided HF and pre-capillary PH [3], [4], [5]. Because of the high variability in RV adaptation to pressure overload and its ability to improve during afterload reduction by a LV assist-device (LVAD) in patients with end-stage CHF or after lung transplantation (LTx) in patients with pre-capillary PH, the reliability of RV assessment is paramount for prognostic evaluations and therapeutic decisions [1], [6], [7].

Echocardiography (echo) is the mainstay for RV evaluation but the markedly load-dependency of RV size, geometry and function induce particular challenges in RV echo-assessment. The review summarizes knowledge about RV echo-assessment in patients with afterload-induced RVF. Special attention is focused on interpretation of RV geometry and function measurements in relation to loading conditions, aiming to evaluate RV adaptability to load and to predict the reversibility of RVF by reduction of RV afterload.

Section snippets

Pathophysiology of RV response to pressure overload

Pressure and volume overload are main causes of RV dysfunction [8], [9]. However, because the compliant thin-walled RV tolerates less pressure than volume overload, the most frequent initial cause of RVF is the pressure overload due to high filling pressures of the LV and/or high pulmonary vascular resistance (PVR) [3], [4], [8].

The onset of pressure overload-induced RVF can be abrupt like in acute massive pulmonary embolism because the RV is poorly constructed to compensate for acute afterload

Reversibility of right ventricular failure by RV afterload reduction

The high load-sensitivity of RV performance, related to the impact of preload and afterload on RV geometry and TR explains RV ability for reverse remodeling and functional improvement after normalization of loading conditions [16], [17]. Sustained afterload increase is associated with homeometric adaptation (without chamber dilation) of RV contractility in order to maintain an adequate SV [8]. After exhaustion of homeometric adaptation and adaptive remodeling (hypertrophy) the RV responds to

Echo-assessment of the RV: limitations and impact of RV load

Because of difficulties in RV volume measurements (complex three-dimensional RV shape, limited echo-window due to RV position, limited definition of RV endocardial surface), 2D-echo-derived RV ejection fraction (EF) is less reliable and therefore, 2D-echo-derived RV volume and EF calculations are not recommended for clinical use or as a standard reference in research [19], [20]. Three-dimensional (3D) echocardiography obviates geometric assumptions and is superior to standard 2D-echo for

RV echo-evaluation in relation with its loading conditions

RV function is proportional to its contractile force and inversely related to its afterload, whereas RV afterload is determined by the filling pressures of the LV and the resistance of the pulmonary circulation [46], [52]. Load-dependency of RV size, geometry and pump function indicates the necessity for RV evaluation in relation with its loading conditions.

In vitro myocardial fiber contractility can be defined by an active-tension to fiber-length relationship [8]. In vivo ventricular

Clinical usefulness of RV echo-evaluation in relation to load

Though limited because of variable methodology, several studies showed that RV systolic function correlates with prognosis across a wide spectrum of pathology [6], [17], [63], [64], [65]. However, although the importance of RV function in management and prognostic assessment of many cardiac diseases is incontestable, it remains yet challenging to incorporate RV systolic dysfunction into practical decision making. Nevertheless RV evaluation in relation to its actual loading conditions can be

Conclusions and future directions

In clinical praxis, echocardiography is the mainstay of RV evaluation. However, in addition to the well known particular challenges and limits in RV echo-assessment, the difficulties in proper interpretation of RV echo-data, due to their high dependence on RV loading conditions and the high variability in RV adaptation to pressure overload, seriously hamper the use of echocardiography for assessment of RV contractile function.

Recent approaches to assess the RV in relation with its actual

Conflicts of interest

No conflicts of interest or grant for this article.

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