Predictors of right ventricular systolic dysfunction in compensated and decompensated heart failure

Unveiling the Systemic Impact of Congestion in Heart Failure: A Narrative Review of Multisystem Pathophysiology and Clinical Implications

Congestion is a key clinical feature of heart failure (HF), contributing to hospitalizations, disease progression, and poor outcomes. While traditionally considered a hemodynamic issue, congestion is now recognized as a systemic process affecting multiple organs. Renal dysfunction arises from impaired perfusion and sodium retention, leading to maladaptive left ventricular remodeling. Hepatic congestion contributes to cholestatic liver injury, while metabolic disturbances drive anemia, muscle wasting, and systemic inflammation. Additionally, congestion disrupts the intestinal barrier and immune function, exacerbating HF progression. Given its widespread impact, effective congestion management requires a shift from a cardiovascular-centered approach to a comprehensive, multidisciplinary strategy. Targeted decongestive therapy, metabolic and nutritional optimization, and immune modulation are crucial in mitigating congestion-related organ dysfunction. Early recognition and intervention are essential to slow disease progression, preserve functional capacity, and improve survival. Addressing HF congestion through personalized, evidence-based strategies is vital for optimizing long-term care and advancing treatment paradigms.

Right Heart Pulmonary Circulation Unit Involvement in Left-Sided Heart Failure: Diagnostic, Prognostic, and Therapeutic Implications

Although long neglected, the right heart (RH) is now widely accepted as a pivotal player in heart failure (HF) either with reduced or preserved ejection fraction. The chronic overload of the pulmonary microcirculation results in an initial phase characterized by right ventricular (RV) hypertrophy, right atrial dilation, and diastolic dysfunction. This progresses to overt RH failure when RV dilation and systolic dysfunction lead to RV-pulmonary arterial (RV-PA) uncoupling with low RV output. In the context of its established relevance to progression of HF, clinicians should consider assessment of the RH with information from clinical assessment, biomarkers, and imaging. Notably, no single parameter can predict prognosis alone in HF. Assessments simultaneously should encompass RV systolic function, pulmonary pressures, an estimation of RV-PA coupling, and RH morphologic features. Despite a large volume of evidence indicating the relevance of RH function to the clinical syndrome of HF, evidence-based management strategies are lacking. Targeting RH dysfunction in HF should be an objective of future investigations, being an unmet need in the current management of HF.

Right ventricular systolic function in hypertensive heart failure

BACKGROUND

Heart failure (HF) is a major cause of cardiovascular admissions and hypertensive heart failure (HHF) is the most common cause of HF admissions in sub-Saharan Africa, Nigeria inclusive. Right ventricular (RV) dysfunction is being increasingly recognized in HF and found to be an independent predictor of adverse outcomes in HF. This study aimed to determine the prevalence of RV systolic dysfunction in HHF by several echocardiographic parameters.

METHODOLOGY

One hundred subjects with HHF were recruited consecutively into the study along with 50 age and sex-matched controls. All study participants gave written informed consent, and had a full physical examination, blood investigations, 12-lead electrocardiogram, and transthoracic echocardiography. RV systolic function was assessed in all subjects using different methods based on the American Society of Echocardiography guidelines for echocardiographic assessment of the right heart in adults. This included tricuspid annular plane systolic excursion (TAPSE), RV myocardial performance index (MPI), and RV systolic excursion velocity by tissue Doppler (S').

RESULTS

RV systolic dysfunction was found in 53% of subjects with HHF by TAPSE, 56% by RV MPI, and 48% by tissue Doppler systolic excursion S'. RV systolic dysfunction increased with reducing left ventricular ejection fraction (LVEF) in subjects with HHF.

CONCLUSION

A high proportion of subjects with HHF were found to have RV systolic functional abnormalities using TAPSE, RV MPI, and RV S'. Prevalence of RV systolic dysfunction increased with reducing LVEF.

Right Ventricular Systolic Dysfunction Is Common in Hypertensive Heart Failure: A Prospective Study in Sub-Saharan Africa

INTRODUCTION

Right ventricular (RV) systolic dysfunction is now recognized widely as a strong and independent predictor of adverse outcomes in patients with heart failure (HF). Reduction of RV systolic function more closely predicts impaired exercise tolerance and poor survival than does left ventricular (LV) systolic function. In spite of this, there is a dearth of data on RV function in hypertensive HF which is the commonest form of HF in sub-Saharan Africa. We therefore conducted a prospective cohort study of hypertensive HF patients presenting to the University of Abuja Teaching Hospital, Abuja, Nigeria over an 8 year period.

METHODS

Each subject had transthoracic echocardiography performed on them according to the guidelines of American Society of Echocardiography. RV systolic function was defined as a tricuspid annular plane systolic excursion (TAPSE) <15 mm using M-mode echocardiography.

RESULTS

RV systolic dysfunction was identified in 272 (44.5%) of the 611 subjects that were studied. Subjects with TAPSE less than 15 mm had worse prognosis compared to those with TAPSE ≥15 mm.There was a significant correlation between TAPSE and other adverse prognostic markers including left and right atrial area, LV size, LV mass, LV ejection fraction, restrictive mitral inflow and RV systolic pressure (RVSP). However, LV ejection fraction and right atrial area were the only independent determinants of RV systolic dysfunction.

CONCLUSIONS

Hypertensive HF is a major cause of RV systolic dysfunction even in a population with a low prevalence of coronary artery disease, and RV systolic dysfunction is associated with poor prognosis in hypertensive HF. Detailed assessment of RV function should therefore be part of the echocardiography evaluation of patients with hypertensive HF.

Gender differences in right ventricular function in patients with non-ischaemic cardiomyopathy

AIM

To evaluate sex-related differences in right ventricular (RV) function, assessed with cardiac magnetic resonance imaging, in patients with stable non-ischaemic dilated cardiomyopathy.

METHODS

Prospective multicentre study. We included 71 patients (38 men) and 14 healthy volunteers.

RESULTS

Mean age was 60.9 ± 12.2 years. Men presented higher levels of haemoglobin and white blood cell counts than women, and performed better in cardiopulmonary stress testing. A total of 24 patients (12 women) presented severe left ventricular (LV) systolic dysfunction, 32 (13 female) moderate and 15 (8 women) mild LV systolic dysfunction. In the group with severe LV systolic dysfunction, average right ventricular ejection fraction (RVEF) was normal in women (52 ± 4 %), whereas it was reduced in men (39 ± 3 %) p = 0.035. Only one woman (8 %) had severe RV systolic dysfunction (RVEF < 35 %) compared with 6 men (50 %) p < 0.001. In patients with moderate and mild LV dysfunction , the mean RVEF was normal in both men and women. In the 14 healthy volunteers, the lowest value of RVEF was 48 % and mean RVEF was normal in women (56 ± 2 %) and in men (51 ±  1 %), p = 0.08.

CONCLUSIONS

In patients with dilated cardiomyopathy, RV systolic dysfunction is found mainly in male patients with severe LV systolic dysfunction.

Assessment of right ventricular dysfunction predictors before the implantation of a left ventricular assist device in end-stage heart failure patients using echocardiographic measures (ARVADE): Combination of left and right ventricular echocardiographic variables

BACKGROUND

Right ventricular failure (RVF) is a major cause of morbidity and mortality in left ventricular assist device (LVAD) recipients.

OBJECTIVES

To identify preoperative echocardiographic predictors of post-LVAD RVF.

METHODS

Data were collected for 42 patients undergoing LVAD implantation in Germany. RVF was defined as the need for placement of a temporary right ventricular assist device or the use of inotropic agents for 14 days. Data for RVF patients were compared with those for patients without RVF. A score (ARVADE) was established with independent predictors of RVF by rounding the exponentiated regression model coefficients to the nearest 0.5.

RESULTS

RVF occurred in 24 of 42 LVAD patients. Univariate analysis identified the following measurements as RVF risk factors: basal right ventricular end-diastolic diameter (RVEDD), minimal inferior vena cava diameter, pulsed Doppler transmitral E wave (Em), Em/tissue Doppler lateral systolic velocity (SLAT) ratio and Em/tissue Doppler septal systolic velocity (SSEPT) ratio. Em/SLAT≥18.5 (relative risk [RR] 2.78, 95% confidence interval [CI] 1.38-5.60; P=0.001), RVEDD≥50 mm (RR 1.97, 95% CI 1.21-3.20; P=0.008) and INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) level 1 (RR 1.74, 95% CI 1.04-2.91; P=0.04) were independent predictors of RVF. An ARVADE score>3 predicted the occurrence of post-implantation RVF with a sensitivity of 89% and a specificity of 74%.

CONCLUSION

The ARVADE score, combining one clinical variable and three echocardiographic measurements, is potentially useful for selecting patients for the implantation of an assist device.