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Implications of right ventricular involvement in diastolic heart failure
- Justin A Woods, Justin Woods, Peter Anderson, Andy Rhodes (13 September 2007)
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Re: Diastolic dysfunction and heart failure
- Ritesh Maharaj (25 June 2007)
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Justin A Woods , Justin Woods, Peter Anderson, Andy Rhodes
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Implications of right ventricular involvement in diastolic heart failure J Woods, P Anderson, A Rhodes Department of Anaesthesia and Intensive Care Medicine St George’s Hospital London SW17 0QT Tel: +44 208 725 0884 Fax: +44 208 725 0879 Email justinwoods@doctors.org.uk Editor – Sir, it is with interest that we read the recent article by Pirracchio et al1 and would like to support their comments further with observations about the usefulness of cardiac neurohormones and the impact of the right ventricle on left ventricular relaxation which they have not considered. The authors correctly identify B-type natriuretic peptide as a potential marker for diastolic dysfunction in the acutely ill patient. However they fail to mention that the diagnostic utility is limited as elevated levels occur in multiple pathologies such as sepsis, respiratory disease, renal failure and subarachnoid haemorrhage. Levels also vary depending on gender and age2,3,4. Thus the diagnostic usefulness of an elevated cardiac neurohormone is questionable although it may serve as a screening tool prior to echocardiography and cardiac catheterisation5,6,7. With respect to left ventricular diastolic relaxation, there is coupling between the two ventricles, represented by the diastolic ventricular interaction and trans-septal pressure gradient. The pericardium constrains the two ventricles such that the combined volumes remain constant at a given point in time but which vary depending on the time course of the cardiac cycle. Under abnormal conditions an elevated right ventricular end diastolic volume may cause the septum to intrude into the left ventricular cavity raising the left ventricular end diastolic pressure. This may then reduce the available volume for filling and impairs left ventricular relaxation, accounting for a decreased left ventricular ejection fraction8,9,10. Multiple causes of right ventricular dysfunction exist including mechanical ventilation10. If there is left ventricular impairment, the upstream component should be considered as a potential cause and appropriately investigated and managed. It should also be borne in mind that inappropriate ventilator settings, such as PEEP, which result in elevated transpulmonary pressures may contribute to the ventricular impairment. The use of preload and afterload reduction in these patients may pose difficulties in the under-filled patient. The elevation of left ventricular end diastolic pressures may give the false impression of adequate cardiac preload. Sequential volume challenges, with appropriate cardiovascular monitoring, may be required in order to optimise cardiac preload and avoid cardiovascular collapse. In conclusion cardiac neurohormones in the critically ill may serve as an indicator of cardiac distress but further diagnostic extrapolation is difficult. Right ventricular involvement may have significant effects on left ventricular relaxation and function and should be sought and the underlying cause corrected. References: 1) Pirracchio R , Cholley B , De Hert S et al Diastolic heart failure in anaesthesia and critical care BJA Advance Access published on June 1, 2007, DOI 10.1093/bja/aem098.Br. J. Anaesth. 98: 707-721 2) Karmpaliotis D, Ajay J, Ruisi C et al Diagnostic and Prognostic Utility of Brain Natriuretic Peptide in Subjects Admitted to the ICU With Hypoxic Respiratory Failure Due to Noncardiogenic and Cardiogenic Pulmonary Edema Chest 2007 131: 964-971 3) Clerico A, Recchia F, Passino C et al Cardiac endocrine function is an essential component of the homeostatic regulation network: physiological and clinical implications Am J Physiol Heart Circ Physiol 290: H17-H29, 2006 4) Phua, J; Lim, Tow K; Lee, Kang H B-type natriuretic peptide: Issues for the intensivist and pulmonologist [Review Articles] Critical Care Medicine:Volume 33(9)September 2005pp 2094 -2013 5) Yap L, Mukerjee D, Timms P et al Natriuretic Peptides, Respiratory Disease, and the Right Heart Chest 2004 126: 1330-1336 6) Krüger S, Graf J, Merx MW, Koch KC, Kunz D, Hanrath P, Janssens U. Brain natriuretic peptide predicts right heart failure in patients with acute pulmonary embolism. Am Heart J. 2004; 147: 60–65 7) Clerico A, Emdin M Diagnostic Accuracy and Prognostic Relevance of the Measurement of Cardiac Natriuretic Peptides: A Review Clin Chem 2004 50: 33-50 8) Jardin, F, Dubourg, O, Bourdarias, JP (1997) Echocardiographic pattern of acute cor pulmonale. Chest 111,209-217 9) Bleasdale, R A, Frenneaux, M P Prognostic importance of right ventricular dysfunction Heart 2002 88: 323-324 10) Woods J, Monteiro P, Rhodes A Right Ventricular Dysfunction Curr Opin Crit Care 2007 Oct, 13:532-540 Conflict of Interest:Dr A Rhodes has worked as a consultant for Edwards Life Sciences and has consucted research partially funded by Edwards. |
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Ritesh Maharaj, Anaestehesia Chelmsford, UK
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Editor- I read with interest the recent review on diastolic heart failure by Pirracchio and colleagues1. Recent community based studies have suggested that isolated diastolic dysfunction is common in patients of advanced age and may precede the development of heart failure2 3. These studies have added credence to the hypothesis that systolic and diastolic heart failure may represent different phenotypes of the same pathophysiological process4. The consensus document from the Heart failure and echocardiography associations of the European Society of Cardiology highlight some of the arguments supporting this single syndrome hypothesis5. Left ventricular ejection fraction is a radially measured parameter. There may be significant radial compensation for impairment longitudinal function. Advances in echocardiography technology such as tissue Doppler imaging (TDI) and strain and strain rate has enables clinicians to appreciate changes in longitudinal function. Several disease modifiers may alter disease progression. Differences in systolic and diastolic heart failure may be more due to differences in disease modifiers than in the two distinct models of heart failure6-8. Disease modifiers include hypertension, diabetes, obesity and the presence of coronary artery disease. In addition diastolic dysfunction is present in about 80% of patients with systolic heart failure. Compared with normal diastolic function, mild diastolic dysfunction in patients without a history of heart failure carries a hazard ratio of 3.1 (95 CI 3.0-23.1 p<.001)3. The prognosis for diastolic dysfunction in combination with systolic heart failure is significantly worse than systolic heart failure alone. I congratulate the authors on their excellent work but suggest that discussion of diastolic heart failure alone without considering diastolic dysfunction would seem incomplete. References 1. Pirracchio R, Cholley B, De Hert S, Solal AC, Mebazaa A. Diastolic heart failure in anaesthesia and critical care. Br J Anaesth 2007;98(6):707-21. 2. Bursi F, Weston SA, Redfield MM, Jacobsen SJ, Pakhomov S, Nkomo VT, et al. Systolic and diastolic heart failure in the community. Jama 2006;296(18):2209-16. 3. Redfield MM, Jacobsen SJ, Burnett JC, Jr., Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. Jama 2003;289(2):194-202. 4. De Keulenaer GW, Brutsaert DL. Systolic and diastolic heart failure: different phenotypes of the same disease? Eur J Heart Fail 2007;9(2):136- 43. 5. Paulus WJ, Tschope C, Sanderson JE, Rusconi C, Flachskampf FA, Rademakers FE, et al. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J 2007. 6. De Keulenaer GW, Brutsaert DL. Diastolic heart failure: a separate disease or selection bias? Prog Cardiovasc Dis 2007;49(4):275-83. 7. Brutsaert DL. Cardiac dysfunction in heart failure: the cardiologist's love affair with time. Prog Cardiovasc Dis 2006;49(3):157-81. 8. Brutsaert DL. Diastolic heart failure: perception of the syndrome and scope of the problem. Prog Cardiovasc Dis 2006;49(3):153-6. Conflict of Interest:None declared |
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