Can indices of left ventricular function be applied to the right ventricle?

The association of Pulmonary Hypertension and right ventricular systolic function - updates in diagnosis and treatment

Right ventricular (RV) systolic function is an essential but neglected component in cardiac evaluation, and its importance to the contribution to overall cardiac function is undermined. It is not only sensitive to the effect of left heart valve disease but is also more sensitive to changes in pressure overload than the left ventricle. Pulmonary Hypertension is the common and well-recognized complication of RV systolic dysfunction. It is also the leading cause of pulmonary valve disease and right ventricular dysfunction. Patients with a high pulmonary artery pressure (PAP) and a low RV ejection fraction have a seven-fold higher risk of death than heart failure patients with a normal PAP and RV ejection fraction. Furthermore, it is an independent predictor of survival in these patients. In this review, we examine the association of right ventricular systolic function with Pulmonary Hypertension by focusing on various pathological and clinical manifestations while assessing their impact. We also explore new 2022 ESC/ERS guidelines for diagnosing and treating right ventricular dysfunction in Pulmonary Hypertension.

Novel Noninvasive Assessment of Pulmonary Arterial Stiffness Using Velocity Transfer Function

Background

Pulmonary artery (PA) stiffness is associated with increased pulmonary vascular resistance (PVR). PA stiffness is accurately described by invasive PA impedance because it considers pulsatile blood flow through elastic PAs. We hypothesized that PA stiffness and impedance could be evaluated noninvasively by PA velocity transfer function (VTF), calculated as a ratio of the frequency spectra of output/input mean velocity profiles in PAs.

Methods and Results

In 20 participants (55±19 years, 14 women) undergoing clinically indicated right‐sided heart catheterization, comprehensive phase‐contrast and cine‐cardiac magnetic resonance imaging was performed to calculate PA VTF, along with right ventricular mass and function. PA impedance was measured as a ratio of frequency spectra of invasive PA pressure and echocardiographically derived PA flow waveforms. Mean PA pressure was 29.5±13.6 mm Hg, and PVR was 3.5±2.8 Wood units. A mixed‐effects model showed VTF was significantly associated with PA impedance independent of elevation in pulmonary capillary wedge pressure (P=0.005). The mean of higher frequency moduli of VTF correlated with PVR (ρ=0.63; P=0.003) and discriminated subjects with low (n=10) versus elevated PVR (≥2.5 Wood units, n=10), with an area under the curve of 0.95, similar to discrimination by impedance (area under the curve=0.93). VTF had a strong inverse association with right ventricular ejection fraction (ρ=−0.73; P<0.001) and a significant positive correlation with right ventricular mass index (ρ=0.51; P=0.02).

Conclusions

VTF, a novel right ventricular–PA axis coupling parameter, is a surrogate for PA impedance with the potential to assess PA stiffness and elevation in PVR noninvasively and reliably using cardiac magnetic resonance imaging.

Pulmonary versus aortic pressure behavior of a bovine pericardial valve

BACKGROUND

The Carpentier Edwards Perimount Magna Ease aortic valvular prosthesis (Edwards Lifesciences, Irvine, Calif) has been among the most frequently and successfully used tissue prosthetic cardiac valves. Furthermore, this prosthesis has been used off-label in the pulmonary position. Until now, there has been a paucity of data regarding the functioning of tissue prosthetic valves under pulmonary conditions.

METHODS

Using a pulse duplicator, hydrodynamic characteristics of a 21-mm and 25-mm Magna Ease valve were evaluated. Among parameters evaluated were leakage orifice area, closing time (ie, time required to close), and leakage duration. This procedure was performed under different pulmonic pressure conditions (15/5 mm Hg, 28/11 mm Hg, 73/32 mm Hg) and normal aortic pressure (120/80 mm Hg) as a reference. Moving images were obtained using a Phantom MIRO M320S high-speed camera (Vision Research Inc, Wayne, NJ) at 600 frames per second and used to analyze valve area in closed position.

RESULTS

Under normal pulmonic conditions (28/11 mm Hg) the leakage orifice area was 0.020 ± 0.012 mm² for the 21-mm valve and 0.054 ± 0.041 mm² for the 25-mm valve (P = .03). Hydrodynamic characteristics of the valves differed between pulmonary and aortic testing condition. Valve closing volumes were significantly lower under pulmonary hypotension and normal pulmonary conditions than under normal aortic conditions (P < .05).

CONCLUSIONS

Under normal pulmonary pressure conditions, the hydrodynamic characteristics of Magna Ease valves are significantly different compared with aortic conditions. Further research is needed to determine whether these results are associated with prosthetic valve failure.

[Pathophysiology of right ventricular hemodynamics]

The right ventricle (RV) plays a key role in the maintenance of an adequate cardiac output whatever the demand, and thus contributes to the optimization of the ventilation/perfusion ratio. The RV has a thin wall and it buffers the physiological increases in systemic venous return without causing a deleterious rise in right atrial pressure (RAP). The RV is coupled to the pulmonary circulation which is a low pressure, low resistance, high compliance system. In the healthy subject at rest, the contribution of the RV to right heart systolic function is surpassed by the contribution of both left ventricular contraction and the respiratory pump. RV systolic function plays a contributory role during exercise and in patients with pulmonary hypertension. The RV compensates better for volume overload than for pressure overload and is more capable of sustaining chronic increases in load than acute ones. An impaired RV-pulmonary artery coupling leads to a major mismatch between RV function and arterial load ("afterload mismatch") and is associated progressively with a low cardiac output and a high RAP. Right ventricular dysfunction is involved in the pathophysiology of both cardiovascular and pulmonary diseases, and may partly explain the deleterious haemodynamic consequences of mechanical ventilation.

The normal impact of age and gender on right heart structure and function

BACKGROUND

As the proportion of elderly population increases rapidly, it might be difficult to differentiate physiological changes in cardiac function due to age from the pathophysiological ones. In addition, cardiac function variations with gender are well established. The right ventricular (RV) plays an important role in the overall cardiac function, but reference values varying with age and gender are lacking.

MATERIAL AND METHODS

We studied 255 healthy individuals from a general population register, mean age of 58 ± 19 (range 22-89) years, 125 were females. We used 2D and M-mode echocardiography to measure RV inflow tract (RVIT) and RV outflow tract (RVOT) dimensions and fractional shortening (fs). Spectral Doppler echocardiography was also used.

RESULTS

We found a modest decrease in RVIT dimensions (P < 0.05), but increase in RVOT dimensions with advancing age (P < 0.05). A small decrease in RVOT fs with age was also found (P < 0.05). Estimated pulmonary pressures and pulmonary vascular resistance increased (P < 0.001) as did RVOT wall thickness (P < 0.001), but RV diastolic function was not altered (P < 0.001) with age. Despite correction for the BSA, males showed larger RVIT dimensions (P < 0.001 for both), but RVOT end-diastolic dimension was larger in females (P < 0.05). RVIT and RVOT fractional shortening were increased in females (P < 0.01 for both).

CONCLUSION

In a cohort of normal individuals, age has significant impact on RV structure and function, inlet area falls and outflow tract dimensions increase and fractional shortening also increase in females. In addition, RVOT wall thickness significantly increases and Doppler markers of pulmonary vascular resistance show a consistent rise. The age-related changes should carefully be considered when commenting on normality and when using absolute values.

Tricuspid regurgitation duration correlates with cardiovascular magnetic resonance-derived right ventricular ejection fraction and predict prognosis in patients with pulmonary arterial hypertension

AIMS

Right ventricular (RV) failure is known to be the main cause of mortality and is closely related to prognosis in patients with pulmonary arterial hypertension (PAH). A decrease in the duration of tricuspid regurgitation corrected for heart rate (TRDc) has recently been shown to be associated with advanced RV failure and poor clinical outcomes. The aim of the present study was to investigate whether TRDc correlates with RV parameters assessed using cardiovascular magnetic resonance (CMR) and has prognostic significance in patients with PAH.

METHODS AND RESULTS

Thirty-seven consecutive patients with PAH (28 females, age 46 ± 14 years) underwent a 6 min walk test, right heart catheterization, echocardiography, and CMR within a 48 h period. Tricuspid regurgitation duration corrected for heart rate, tricuspid annular plane systolic excursion (TAPSE), Tei index, and tricuspid valve lateral annular systolic velocity were measured on echocardiography, and RV end-systolic and end-diastolic volumes and ejection fraction were measured on CMR. Tricuspid regurgitation duration corrected for heart rate was positively correlated with RV ejection fraction as measured on CMR (r = 0.400, P = 0.014). On multivariate regression analysis, TRDc was also significantly correlated with RV ejection fraction even after adjusting for the eccentric index, Tei index, and TAPSE (P = 0.034). During a median follow-up period of 487 days, there were seven events (19%) including two cardiac deaths and five inpatient admissions for heart failure. The event-free survival rate was significantly higher for patients with TRDc >400 ms than those with TRDc ≤400 ms (P = 0.040).

CONCLUSION

Tricuspid regurgitation duration corrected for heart rate correlated with CMR-derived RV ejection fraction, and decreased TRDc was associated with cardiovascular mortality and rehospitalization in patients with PAH. Therefore, TRDc could be a useful echocardiographic surrogate marker for predicting RV dysfunction and prognosis in patients with PAH.

Role of cardiac magnetic resonance imaging in the management of patients with pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a progressive disorder characterized by abnormally elevated blood pressure of the pulmonary circulation that results, over time, from extensive vascular remodeling and increased pulmonary vascular resistance. Recent advances in magnetic resonance imaging (MRI) technology have led to the development of techniques for noninvasive assessment of cardiovascular structure and function, including hemodynamic parameters in the pulmonary circulation, which are superior in their identification of right ventricular morphologic changes. These advantages make cardiac MRI an attractive modality for following up and providing prognoses in patients with PAH. In this review, we summarize recent developments in the use of MRI for the diagnosis, assessment, and ongoing monitoring of patients with PAH. Over the coming decade, it can be anticipated that continued improvements in MRI image acquisition, spatial and temporal resolution, and analytical techniques will result in improved understanding of PAH pathophysiology, diagnosis, and prognostic variables, and will supplement, and may even replace, some of the invasive procedures currently applied routinely to the evaluation of PAH.

Impaired right ventricular systolic function demonstrated by reduced atrioventricular plane displacement in adults with Marfan syndrome

AIMS

The right ventricle (RV) ejects the same volume of blood at the same rate as the left ventricle (LV). Mild LV dysfunction has been demonstrated in Marfan syndrome (MFS). However, little attention has been paid to the functioning of the RV. The aim of this study was to assess RV function in unoperated adult MFS patients.

METHODS AND RESULTS

In 66 unoperated (15-58 years) MFS patients and 61 controls, rate of pressure rise (dp/dt) in RV, and tricuspid annular motion (TAM) were studied using conventional echocardiography and tissue Doppler imaging (TDI). When compared with controls, MFS patients showed impaired RV systolic function as expressed by a reduced dp/dt, TAM obtained by M-mode echocardiography, and peak TDI systolic velocities at the basal lateral wall (745.36+/-37.85 vs. 1103.30+/-27.30 mmHg, P<0.001; 2.2+/-0.05 vs. 2.5+/-0.05 cm, P<0.001; and 0.13+/-0.002 vs. 0.16+/-0.002 m/s, P<0.001, respectively).

CONCLUSION

This study demonstrated a primary impairment of RV systolic function in MFS. This is the first study to report RV dysfunction in MFS. Such data could prove valuable during the peri-operative and long-term medical management of MFS patients.

Comparison between single-beat and multiple-beat methods for estimation of right ventricular contractility

OBJECTIVE

It was investigated whether pharmacologically induced changes in right ventricular contractility can be detected by a so-called "single-beat" method that does not require preload reduction.

DESIGN

Prospective animal research.

SETTING

Laboratory at a large university medical center.

SUBJECTS

Eight anesthetized pigs.

INTERVENTIONS

End-systolic elastance values obtained by a recently proposed single-beat method (Eessb) were compared with those obtained using the reference multiple-beat method (Eesmb).

MEASUREMENTS AND MAIN RESULTS

Administration of dobutamine increased Eesmb from 1.6 +/- 0.3 to 3.8 +/- 0.5 mm Hg/mL (p =.001), whereas there was only a trend toward an increase in Eessb from 1.5 +/- 0.2 to 1.7 +/- 0.4 mm Hg/mL. Esmolol decreased Eesmb from 1.7 +/- 0.3 to 1.1 +/- 0.2 mm Hg/mL (p =.006), whereas there was only a trend for a decrease in Eessb from 1.5 +/- 0.2 to 1.3 +/- 0.1.

CONCLUSIONS

The present method using single-beat estimation to assess right ventricular contractility does not work as expected, since it failed to detect either increases or decreases in right ventricular contractility induced by pharmacologic interventions.

Echocardiographic Assessment of the Right Ventricular Stress-Velocity Relationship Under Normal and Chronic Overload Conditions

The effects of chronic volume or pressure overload on the velocity of right ventricular ejection have not been previously well defined. We hypothesized that, as formerly shown for the left ventricle, there would be a direct relationship between the velocity of ejection and an estimate of systolic wall stress.

METHODS

Echocardiograms of asymptomatic patients, not on cardiac medications, with either an isolated secundum atrial septal defect > or = 5 mm in diameter or isolated pulmonic stenosis with a peak instantaneous pressure gradient > or = 20 mmHg, were reviewed. Forty-one patients with an atrial septal defect and 34 with pulmonary stenosis met criteria, and were compared to age-matched normal controls. Total subjects were 127 with ages ranging from 1 day to 54 years. Right ventricular monoplane ejection fraction, ejection time corrected for heart rate (ETc), mean normalized systolic ejection rate (MNSERc) and meridianal peak-systolic wall stress (WSps) were measured.

RESULTS

Compared to controls, ejection fractions were not significantly different, but WSps averaged 81% and 110% higher, ETc 8% and 9% longer, and MNSERc 5% and 9% slower in the atrial septal defect and pulmonary stenosis groups, respectively. Among all subjects WSps had a significant linear correlation with ETc (r = 0.61, P < 0.01), MNSERc (r =-0.46, P < 0.01), and ejection fraction (r =-0.19, P < 0.05).

CONCLUSIONS

Increases in WSps cause an incremental slowing of MNSERc in the right ventricle, with a relationship that is linear over a wide range of normal and abnormal loading conditions.

Right ventricular adaptation to pulmonary hypertension: an interspecies comparison

Right ventricular (RV) adaptation is an important prognostic factor in acute and chronic pulmonary hypertension. Pulmonary vascular basal tone and hypoxic reactivity are known to vary widely between species. We investigated how RV adaptation to acute pulmonary hypertension is preserved in species with low, intermediate, and high pulmonary vascular resistance and reactivity. Acute pulmonary hypertension was induced by hypoxia, distal embolism, and proximal constriction in anesthetized dogs (n = 10), goats (n = 8), and pigs (n = 8). Pulmonary vessels were assessed by flow-pressure curves and by impedance to quantify distal resistance, proximal elastance, and wave reflections. RV function was assessed by pressure-volume curves to quantify afterload, contractility, and ventricular-arterial coupling efficiency. First, hypoxia was associated with a progressive increase of resistance, elastance, and wave reflection from dogs to goats and from goats to pigs. RV contractility increased proportionally to RV afterload, and optimal coupling was preserved in all species. Second, embolism increased resistance and wave reflection but not elastance. The increase in RV contractility matched the increase in RV afterload and optimal coupling was preserved. Finally, proximal pulmonary artery constriction increased resistance, increased and accelerated wave reflection, and markedly increased elastance. RV contractility increased markedly and coupling showed a nonsignificant trend to decrease. We conclude that optimal or near-optimal ventricular-arterial coupling is maintained in acute pulmonary hypertension, whether in absence or presence of chronic species-induced pulmonary hypertension.

ECG-gated 99mTc single-photon emission CT for assessment of right ventricular structure and function: is the information provided similar to echocardiography?

STUDY OBJECTIVE

(99m)Tc single-photon emission CT (SPECT) and ECG-gated SPECT can visualize well the right ventricle (RV) in most patients, but their utility for assessment of the RV has not been formally evaluated. We examined whether (99m)Tc SPECT/ECG-gated SPECT provide similar information to transthoracic two-dimensional Doppler echocardiography (2D-ECHO) regarding RV cavity size, wall thickness, and systolic function.

DESIGN

Retrospective analysis.

SETTING

A major university teaching hospital.

PATIENTS

A consecutive series of 194 patients with good quality stress SPECT and 2D-ECHO studies performed within 1 day of each other and no significant interim cardiac events.

MEASUREMENTS AND RESULTS

RV size and function were visually assessed by SPECT/ECG-gated SPECT and 2D-ECHO. RV wall thickness was visually assessed by SPECT and measured in mm in end-diastole by 2D-ECHO. Of 142 patients with normal RV cavity size by SPECT, 134 patients (94%) had normal RV cavity size by 2D-ECHO. However, of 52 patients with RV dilation by SPECT, only 9 patients (17%) had RV dilation by 2D-ECHO. A perfusion abnormality in the right coronary artery territory was significantly associated with RV dilation by SPECT (p < 0.005) and 2D-ECHO (p < 0.05). Among 150 patients with ECG-gated SPECT, only 2 patients had abnormal RV systolic function, as compared with 18 patients by 2D-ECHO. RV wall thickness measurements by SPECT and 2D-ECHO did not correlate.

CONCLUSIONS

For normal interpretations regarding RV cavity size, wall thickness, and systolic function, there is good agreement between (99m)Tc stress SPECT/ECG-gated SPECT and 2D-ECHO. However, there is poor overall agreement between gated SPECT/ECG-gated SPECT and 2D-ECHO regarding the presence of RV dilation, hypertrophy, and systolic dysfunction.

Simultaneous vs. sequential biventricular pacing in dilated cardiomyopathy: an acute hemodynamic study

AIMS

Simultaneous biventricular pacing improves left ventricular (LV) systolic performance in patients with dilated cardiomyopathy and intraventricular conduction delay. We tested the hypothesis that further improvements can be obtained using sequential biventricular pacing by optimizing both atrioventricular and interventricular delays.

METHODS AND RESULTS

In 12 patients, LV pressure, right ventricular (RV) pressure and respective rates of change of pressure (dP/dt) were acutely measured during biventricular pacing with different atrioventricular and interventricular (VVi) intervals ranging from -60 to +40 ms. The average increase vs. baseline in maximum LV dP/dt was higher for sequential than for simultaneous biventricular pacing (VDD mode: 35+/-20 vs. 29+/-18%, P<0.01; DDD mode: 38+/-23 vs. 34+/-25%, P<0.01), with a minority of patients accounting for most of the difference. The mean optimal VVi was -25+/-21 ms in VDD mode and -25+/-26 ms in DDD mode. With these settings, RV dP/dt was not significantly different from baseline. QRS shortening was not predictive of LV dP/dt increase.

CONCLUSION

A significant increase of LV dP/dt with no change in RV dP/dt can be obtained by sequential biventricular pacing as compared to simultaneous biventricular pacing. The highest LV dP/dt is achieved when LV is stimulated before RV. The hemodynamic advantage might be of clinical significance in selected cases.

Single-beat estimation of right ventricular end-systolic pressure-volume relationship

Assessment of right ventricular (RV) contractility from end-systolic pressure-volume relationships (ESPVR) is difficult due to problems in measuring RV instantaneous volume and to effects of changes in RV preload or afterload. We therefore investigated in anesthetized dogs whether RV ESPVR and contractility can be determined without measuring RV volume and without changing RV preload or afterload. The maximal RV pressure of isovolumic beats (P(max)) was predicted from isovolumic portions of RV pressure during ejecting beats and compared with P(max) measured during the first beat after pulmonary artery clamping. In RV pressure-volume loops obtained from RV pressure and integrated pulmonary arterial flow, end-systolic elastance (E(es)) was assessed as the slope of P(max)-derived ESPVR, pulmonary artery effective elastance (E(a)) as the slope of end-diastolic to end-systolic relation, and coupling efficiency as the E(es)-to-E(a) ratio (E(es)/E(a)). Predicted P(max) correlated with observed P(max) (r = 0.98 +/- 0.02). Dobutamine increased E(es) from 1.07 to 2.00 mmHg/ml and E(es)/E(a) from 1.64 to 2.49, and propranolol decreased E(es)/E(a) from 1.64 to 0.91 (all P < 0.05). After adrenergic blockade, preload reduction did not affect E(es), whereas hypoxia and arterial constriction markedly increased E(a) and somewhat increased E(es) due to the Anrep effect. Low preload did not affect E(es)/E(a) and high afterload decreased E(es)/E(a). In conclusion, in the right ventricle 1) P(max) can be calculated from normal beats, 2) P(max) can be used to determine ESPVR without change in load, and 3) P(max)-derived ESPVR can be used to assess ventricular contractility and ventricular-arterial coupling efficiency.

Preload recruitable stroke work relationship in the right ventricle: simultaneous assessment using conductance catheter and sonomicrometry

OBJECTIVE

To examine the suitability of the conductance catheter technique for assessment of right ventricular systolic myocardial performance by using preload recruitable stroke work, we compared variables obtained simultaneously by conductance catheter and sonomicrometry dimension techniques. In addition, linearity of volume relationships was studied during rapid preload alteration by bicaval occlusion.

DESIGN

Prospective animal study.

SETTING

University research laboratory.

SUBJECTS

Anesthetized and ventilated swine (n = 9).

INTERVENTIONS

Right intraventricular volumes were determined simultaneously by conductance catheter and sonomicrometry by using an ellipsoid shell subtraction model in open-chest swine. Animals were studied at the baseline state and under alterations of afterload, preload, and inotropy. Under each condition, steady-state recordings and transient bicaval occlusions were performed. Agreement of preload recruitable stroke work slope was assessed by using the Bland-Altman analysis, and second-order polynomials were fit to examine volume relationships during bicaval occlusions.

MEASUREMENTS AND MAIN RESULTS

At steady state, the relationships for stroke-volumes and end-diastolic volumes were linear between the two methods. Altered physiologic conditions induced by the various interventions produced quantitatively similar changes in preload recruitable stroke work slope within an animal, although absolute values differed in some animals. Regression analysis of the preload recruitable stroke work slope revealed a significant intervention effect independent of the method used. During some bicaval occlusions, nonlinear relationships were observed similarly with both methods.

CONCLUSIONS

These results suggest that changes in right ventricular systolic contractility assessed by the preload recruitable stroke work relationship were similar when measured by conductance catheter and sonomicrometry, although absolute values may differ in some animals.

Detection of early right ventricular dysfunction in Chagas' disease using Doppler tissue imaging

BACKGROUND

The involvement of the right ventricle (RV) in Chagas' disease is frequent. Although echocardiography plays an important role in noninvasive assessment of cardiac function, evaluation of RV is challenging because of the anatomic and functional complexity of this chamber.

METHODS

To study early functional abnormalities in the RV, we selected 18 patients with Chagas' disease, no other disease, and a normal echocardiogram; and 12 normal individuals as a control group. All participants were submitted to Doppler tissue imaging and the parameters of systolic (systolic wave and regional isovolumic contraction time) and diastolic (early and late expansion waves) function were analyzed at the level of the interventricular septum and free wall of the RV.

RESULTS

Regional isovolumic contraction time values showed a statistically significant difference between the 2 groups both in the RV free (P =.0003) and septal (P =.003) walls. With respect to diastolic function, we observed a significant difference between groups involving the early expansion wave (P =.014) and e/a ratio (P =.004) of the RV free wall.

CONCLUSION

Doppler tissue imaging proved to be useful in early detection of RV dysfunction in Chagas' disease, with potential use in risk stratification of these patients.

Increased brain and atrial natriuretic peptides in patients with chronic right ventricular pressure overload: correlation between plasma neurohormones and right ventricular dysfunction

OBJECTIVE

To evaluate the role of plasma neurohormones in the diagnosis of asymptomatic or minimally symptomatic right ventricular dysfunction.

SETTING

Tertiary cardiovascular referral centre.

METHODS

Plasma brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) concentrations were measured in 21 asymptomatic or minimally symptomatic patients with chronic right ventricular pressure overload caused by congenital heart disease, and in seven healthy volunteers. Right ventricular ejection fraction was determined using magnetic resonance imaging.

RESULTS

Right ventricular ejection fraction in the volunteers was higher than in the patients (69.0 (8.2)% v 58.0(12.0)%, respectively; p < 0.006). Left ventricular ejection fraction was 72.3(7.8)% in volunteers and 68.1(11.0)% in patients (NS). There was a significant difference between patients and volunteers in the plasma concentrations of BNP (5.3 (3.5) v 2.3 (1.7) pmol/l, respectively; p < 0.009) and ANP (7.3 (4.5)v 3.6 (1.4) pmol/l; p < 0.05). In both patients and volunteers, mean plasma ANP was higher than mean plasma BNP. Right ventricular ejection fraction was inversely correlated with BNP and ANP (respectively, r = 0.65; p < 0.0002 and r = 0.61; p < 0.002). There was no correlation between left ventricular ejection fraction and BNP (r = 0.2; NS) or ANP (r = 0.52; NS). Similarly, no correlation was shown between the level of right ventricular systolic pressure and either plasma BNP (r = 0.20) or plasma ANP (r = 0.07).

CONCLUSIONS

There was a significant inverse correlation between right ventricular ejection fraction and the plasma neurohormones BNP and ANP in asymptomatic or minimally symptomatic patients with right ventricular pressure overload and congenital heart disease. Monitoring changes in BNP and ANP may provide quantitative follow up of right ventricular dysfunction in these patients.

Increased brain and atrial natriuretic peptides in patients with chronic right ventricular pressure overload: correlation between plasma neurohormones and right ventricular dysfunction

OBJECTIVE

To evaluate the role of plasma neurohormones in the diagnosis of asymptomatic or minimally symptomatic right ventricular dysfunction.

SETTING

Tertiary cardiovascular referral centre.

METHODS

Plasma brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) concentrations were measured in 21 asymptomatic or minimally symptomatic patients with chronic right ventricular pressure overload caused by congenital heart disease, and in seven healthy volunteers. Right ventricular ejection fraction was determined using magnetic resonance imaging.

RESULTS

Right ventricular ejection fraction in the volunteers was higher than in the patients (69.0 (8.2)% v 58.0(12.0)%, respectively; p < 0.006). Left ventricular ejection fraction was 72.3(7.8)% in volunteers and 68.1(11.0)% in patients (NS). There was a significant difference between patients and volunteers in the plasma concentrations of BNP (5.3 (3.5) v 2.3 (1.7) pmol/l, respectively; p < 0.009) and ANP (7.3 (4.5) v 3.6 (1.4) pmol/l; p < 0.05). In both patients and volunteers, mean plasma ANP was higher than mean plasma BNP. Right ventricular ejection fraction was inversely correlated with BNP and ANP (respectively, r = 0.65; p < 0.0002 and r = 0.61; p < 0.002). There was no correlation between left ventricular ejection fraction and BNP (r = 0.2; NS) or ANP (r = 0.52; NS). Similarly, no correlation was shown between the level of right ventricular systolic pressure and either plasma BNP (r = 0.20) or plasma ANP (r = 0.07).

CONCLUSIONS

There was a significant inverse correlation between right ventricular ejection fraction and the plasma neurohormones BNP and ANP in asymptomatic or minimally symptomatic patients with right ventricular pressure overload and congenital heart disease. Monitoring changes in BNP and ANP may provide quantitative follow up of right ventricular dysfunction in these patients.