Investigating the effects of systemic thrombolysis on electrocardiography and pulmonary artery blood pressure in patients with pulmonary embolism.

Background and Aims: We aimed to evaluate the association between electrocardiography (ECG) and echocardiographic findings in patients with pulmonary embolism (PE) before and after systemic thrombolysis. Methods: We included 38 PE patients admitted to the hospital with approved right ventricular (RV) dysfunction who were indicated for systemic thrombolysis. Indications for systemic thrombolysis were considered as patients who were either hemodynamically unstable on admission or became unstable in the course of hospital admission. Systemic thrombolysis was performed by either Reteplase or Alteplase. ECG and echocardiographic findings were documented at baseline and 12-24 h following systemic thrombolysis. Results: Our results showed that TAPSE significantly increased while RV size and pulmonary artery systolic pressure (PAP) notably decreased after systemic thrombolysis (p < 0.001). The ECG abnormalities markedly diminished after systemic thrombolysis in PE patients (p < 0.001). Additionally, 100% of our patients had more than one ECG abnormality at baseline, while 55.3% had no ECG abnormalities after systemic thrombolysis. Further, the median number of ECG abnormalities remarkably attenuated after systemic thrombolysis (from 2.0 (1.0) to 0.0 (1.0), p < 0.001). Our results also revealed that delta RV size (r = 0.51, p = 0.001) and delta TAPSE (r = 0.4, p = 0.012) were positively correlated while mortality (r = -0.55, p = 0.001) was negatively associated with changes in the number of ECG abnormalities before and after systemic thrombolysis. Conclusion: We showed that systemic thrombolysis improved echocardiographic and electrocardiographic findings in PE patients. Additionally, a greater decreased number of ECG abnormalities after systemic thrombolysis was accompanied by more improvement in RV size and TAPSE and a lower mortality rate.

Impact of Right Ventricular Dysfunction on Outcomes in Acute Myocardial Infarction and Cardiogenic Shock: Insights from the National Cardiogenic Shock Initiative.

BACKGROUND: Right ventricular dysfunction (RVD) complicates 30%-40% of cases in acute myocardial infarction (AMI) and cardiogenic shock (CS). There are sparse data on the effects of RVD on outcomes and the impact of providing early left ventricular (LV) mechanical circulatory support (MCS) on RV function and hemodynamics. METHODS AND RESULTS: Between July 2016 and December 2020, 80 sites participated in the study. All centers agreed to treat patients with AMI-CS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of LV-MCS. RVD was defined as a right atrial (RA) pressure of >12 mm Hg and a pulmonary artery pulsatility index (PAPI) of <1 within 24 hours of the index procedure. The primary outcome was survival to discharge. In a subgroup analysis, data available from the Automated Impella Controller console was used to analyze diastolic suction alarms from LV placement signal and its relation to RVD. A total of 361 patients were included in the analysis, of whom 28% had RVD. The median age was 64 years (interquartile range 55-72 years), 22.7% were female and 75.7% were White. There was no difference in age, sex, or comorbidities between those with or without RVD. Patients with RVD had a higher probability of active CPR during LV-MCS implant (14.7% vs 6.3%), Society for Cardiovascular Angiography and Interventions stage E shock (39.2% vs 23.2%), and higher admission lactate levels (5.1 mg/dL vs 3.0 mg/dL). Survival to discharge was significantly lower among those with RVD (61.8% vs 73.4%, odds ratio 0.89, 95% confidence interval 0.36-0.95, P = .031). This association remained significant in the multivariate analysis. There was no significant difference in hemodynamic variables within 24 hours of LV-MCS support among those with or without RVD. At 24 hours, patients with a CPO of >0.6 W and a PAPi of >1 had a trend toward better survival to discharge compared with those with a CPO of ≤0.6 W and a PAPi of ≤1 (77.1% vs 54.6%, P = .092). Patients with RVD were significantly more likely to have diastolic suction alarms within 24 hours of LV-MCS initiation. CONCLUSIONS: RVD in AMI-CS is common and associated with worse survival to discharge. Early LV-MCS decreases filling pressures rapidly within the first 24 hours and decreases the rate of RVD. Achieving a CPO of >0.6 W and a PAPi of >1 within 24 hours is associated with high survival. Diastolic suction alarms may have usefulness as an early marker of RVD.

Pulmonary Embolism and Right Ventricular Dysfunction: Mechanism and Management.

Pulmonary embolism (PE) occurs when thrombi from deep vein thrombosis dislodge and obstruct pulmonary arteries, raising pulmonary artery pressure and straining the right ventricle. This strain can lead to right ventricular dysfunction (RVD), characterized by reduced cardiac output, impaired contractility, and potential development of chronic thromboembolic pulmonary hypertension. Clinically, PE may present with symptoms such as dyspnea, pleuritic chest pain, and tachycardia. Diagnosis is typically confirmed through computed tomography pulmonary angiography, biomarkers like D-dimer and cardiac troponins, and clinical scoring systems. Acute management focuses on hemodynamic support, including intravenous fluids and vasopressors, and may involve anticoagulation with low-molecular-weight heparin or direct oral anticoagulants. Severe cases may require systemic anticoagulation, catheter-directed techniques, and surgeries like pulmonary endarterectomy. Long-term management involves continued anticoagulation tailored to individual risk factors, with ongoing monitoring to prevent recurrence. Effective early diagnosis and management are crucial, as severe PE can significantly increase mortality and lead to serious complications. This review explores the pathophysiology, diagnosis, and management of PE and RVD.

A multimodal approach identifies lactate as a central feature of right ventricular failure that is detectable in human plasma.

Background: In PAH metabolic abnormalities in multiple pathways are well-recognized features of right ventricular dysfunction, however, prior work has focused mainly on the use of a single "omic" modality to describe a single deranged pathway. We integrated metabolomic and epigenomic data using transcriptomics in failing and non-failing RVs from a rodent model to provide novel mechanistic insight and translated these findings to accessible human specimens by correlation with plasma from PAH patients. Methods: Study was conducted in a doxycycline-inducible BMPR2 mutant mouse model of RV failure. Plasma was collected from controls and PAH patients. Transcriptomic and metabolomic analyses were done on mouse RV tissue and human plasma. For mouse RV, we layered metabolomic and transcriptomic data for multiple metabolic pathways and compared our findings with metabolomic and transcriptomic data obtained for human plasma. We confirmed our key findings in cultured cardiomyocyte cells with BMPR2 mutation. Results: In failing mouse RVs, (1) in the glycolysis pathway, glucose is converted to lactate via aerobic glycolysis, but may also be utilized for glycogen, fatty acid, and nucleic acid synthesis, (2) in the fatty acid pathway, FAs are accumulated in the cytoplasm because the transfer of FAs to mitochondria is reduced, however, the ß-oxidation pathway is likely to be functional. (3) the TCA cycle is altered at multiple checkpoints and accumulates citrate, and the glutaminolysis pathway is not activated. In PAH patients, plasma metabolic and transcriptomic data indicated that unlike in the failing BMPR2 mutant RV, expression of genes and metabolites measured for the glycolysis pathway, FA pathway, TCA cycle, and glutaminolysis pathway were increased. Lactate was the only metabolite that was increased both in RV and circulation. We confirmed using a stable isotope of lactate that cultured cardiomyocytes with mutant BMPR2 show a modest increase in endogenous lactate, suggesting a possibility of an increase in lactate production by cardiomyocytes in failing BMPR2 mutant RV. Conclusion: In the failing RV with mutant BMPR2, lactate is produced by RV cardiomyocytes and may be secreted out, thereby increasing lactate in circulation. Lactate can potentially serve as a marker of RV dysfunction in PAH, which warrants investigation.

Intravenous Levosimendan versus Inhalational Milrinone in the Management of Pulmonary Hypertension during Adult Cardiac Surgery: A Randomized Clinical Trial.

Introduction: The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery is challenging, mainly due to the potential risk of right ventricular failure (RVF). Levosimendan is a calcium-sensitizing agent that has primarily been used in the treatment of decompensated heart failure. However, recently levosimendan has been shown to be an effective and safe therapeutic strategy for patients with pulmonary arterial hypertension and PH associated with left heart disease. The aim of this study was to investigate the potential utility of the preemptive administration of levosimendan in cardiac surgical patients with preexisting PH and to compare its effectiveness with milrinone, which represents an already established therapeutic option in the management of PH during cardiac surgery. Materials and Methods: In this study, 40 adult cardiac surgical patients with PH were randomly assigned to receive either levosimendan intravenously or milrinone via inhalation in a double-blind fashion prior to a cardiopulmonary bypass (CPB). Hemodynamic and echocardiographic parameters were recorded and evaluated before and after the administration of the drugs. Results and Conclusions: The results of this study demonstrated that both levosimendan and milrinone administered before CPB in cardiac surgical patients with PH may offer protective benefits, reducing pulmonary artery pressure and preventing the exacerbation of PH and RVF. Pulmonary vasodilation attributed to levosimendan is of longer duration and greater magnitude compared to pulmonary vasodilation afforded by milrinone.

Right ventricular function and determining factors of dysfunction in ST-segment-elevation myocardial infarction: a cross-sectional study with cardiac magnetic resonance imaging (MRI).

Background: Over the past few decades, left ventricular (LV) dysfunction in ST-segment elevation myocardial infarction (STEMI) patients has been the focus of research. Recently, co-occurring right ventricular (RV) dysfunction has received more attention in clinical practice. We aimed to assess RV function using cardiac magnetic resonance (CMR) imaging and identify factors that may contribute to RV dysfunction in STEMI patients. Methods: We retrospectively studied 189 patients with STEMI who underwent CMR 1-7 days after successful percutaneous coronary intervention (PCI). The ejection fraction (EF), wall thickening rate (WTR), peak radial strain (RS), circumferential strain (CS) and longitudinal strain (LS) of the LV, interventricular septum (IVS) and RV were measured with cine images. The location and extent of the infarct were determined using late gadolinium enhancement (LGE) imaging. The differences of function between STEMI patients with right ventricular ejection fraction (RVEF) <50% and those with RVEF ≥50% were compared using an independent-sample t-test. Linear regression analyses were used to determine independent predictors of RVEF. Results: RVEF <50% was observed in 32.28%% STEMI patients, who also demonstrated significantly lower left ventricular ejection fraction (LVEF), WTR, RS, CS, LS and larger infarct sizes than those with RVEF ≥50%. Patients with RVEF <50% also demonstrated a higher incidence of RV infarction, higher RV end-systolic volume (ESV) index, and lower RV RS and CS. Multivariable linear regression analysis revealed LV EF, IVS WTR and IVS RS as significant predictors for RVEF, while male gender, the culprit lesion in the right coronary artery (RCA), peak troponin were negative predictors for RVEF. Notably, peak troponin, LV EF, LV RS, LV CS, LV WTR, and IVS WTR demonstrated higher area under the curve (AUC) values for predicting RV dysfunction. Conclusions: RV dysfunction was detected in 32.28% of STEMI patients. Patients with acute STEMI and RVEF <50% had impaired LV and IVS functions. Systolic function of the LV and IVS, peak troponin, and culprit lesions in the RCA were independent predictors of RV dysfunction in STEMI patients.

Multimodality Imaging for Right Ventricular Function Assessment in Severe Tricuspid Regurgitation.

Severe tricuspid regurgitation (TR) is a pathological condition associated with worse cardiovascular outcomes. In the vicious cycle of right ventricular compensation and maladaptation to TR, the development of right ventricle (RV) dysfunction has significant prognostic implications, especially in patients undergoing surgical or percutaneous treatments. Indeed, RV dysfunction is associated with increased operative morbidity and mortality in both surgical and percutaneously treated patients. In this context, the identification of clinical or subtle right ventricle dysfunction plays a critical role inpatient selection and timing of surgical or percutaneous tricuspid valve intervention. However, in the presence of severe TR, evaluation of RV function is challenging, given the increase in preload that may lead to an overestimation of systolic function for the Frank-Starling law, reduced reliability of pulmonary artery pressure estimation, the sensitivity of RV to afterload that may result in afterload mismatch after treatment. Consequently, conventional echocardiographic indices have some limitations, and the use of speckle tracking for right ventricular free wall longitudinal strain (RV-FWLS) analysis and the use of 3D echocardiography for RV volumes and ejection fraction estimation are showing promising data. Cardiac magnetic resonance (CMR) represents the gold standards for volumes and ejection fraction evaluation and may add further prognostic information. Finally, cardiac computer tomography (CCT) provides measurements of RV and annulus dimensions that are particularly useful in the transcatheter field. Identification of subtle RV dysfunction may need, therefore, more than one imaging technique, which will lead to tip the balance between medical therapy and early intervention towards the latter before disease progression. Therefore, the aim of this review is to describe the main imaging techniques, providing a comprehensive assessment of their role in RV function evaluation in the presence of severe TR.

Right Ventricular to Pulmonary Artery Uncoupling Is Associated With Impaired Exercise Capacity in Patients With Transthyretin Cardiac Amyloidosis.

BACKGROUND: Exercise capacity is related to mortality and morbidity in heart failure (HF) patients. Determinants of exercise capacity in transthyretin cardiac amyloidosis (ATTR-CA) have not been established. METHODS AND RESULTS: This single-center study retrospectively evaluated ATTR-CA patients and patients with non-amyloidosis HF with preserved/mildly reduced ejection fraction (HFpEF/HFmrEF) (n=32 and n=51, respectively). In the ATTR-CA group, the median age was 75.5 years (interquartile range [IQR] 71.3-78.8 years), 90.6% were male, and the median left ventricular (LV) ejection fraction was 53.5% (IQR 41.4-65.6%). Cardiopulmonary exercise tests revealed a median peak oxygen consumption and anaerobic threshold of 15.9 (IQR 11.6-17.4) and 10.6 (IQR 8.5-12.0] mL/min/kg, respectively, and ventilatory efficiency (minute ventilation/carbon dioxide production [V̇E/V̇CO2] slope) of 35.5 (IQR 32.0-42.5). Among exercise variables, V̇E/V̇CO2slope has the greatest prognostic value. Univariate analysis revealed a significant correlation between V̇E/V̇CO2slope and age, LV global longitudinal strain, tricuspid annular plain systolic excursion/pulmonary arterial systolic pressure (TAPSE/PASP) ratio, and mixed venous oxygen saturation. In multivariate analyses, the TAPSE/PASP ratio was an independent predictor of V̇E/V̇CO2slope (95% confidence interval -44.5, -10.8; P=0.0067). In non-amyloidosis HFpEF/HFmrEF patients, the TAPSE/PASP ratio was not independently correlated with V̇E/V̇CO2slope. CONCLUSIONS: Right ventricular-pulmonary artery coupling estimated by the TAPSE/PASP ratio determines exercise capacity in ATTR-CA patients. This highlights the importance of early therapeutic intervention against underappreciated right ventricular dysfunction associated with ATTR-CA.

Prognostic value of right ventricular dysfunction in aortic regurgitation after transcatheter aortic valve replacement.

Background: Aortic regurgitation (AR) may lead to right ventricular dysfunction (RVD), but the prognostic value of RVD in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear. Our goal was to evaluate the clinical implications, predictors and prognostic significance of RVD in patients with pure AR after TAVR. Methods: In this multicentre prospective study, patients undergoing TAVR were included between January 2019 and April 2021. The patients were divided into four groups according to the results of transthoracic echocardiography pre- and post-TAVR. The primary end point was 2-year all-cause mortality. Results: A total of 648 patients were divided into four groups: 325 patients (54.3%) in the no RVD group; 106 patients (17.7%) in the new-onset RVD group; 73 patients (12.2%) in the normalized RVD group; and 94 patients (15.7%) in the residual RVD group. At the 2-year follow-up, there were significant differences in all-cause mortality among the four groups (5.2%, 12.3%, 11.0% and 17.0%, respectively; p < 0.05). New-onset RVD was correlated with an increased risk of all-cause death and a composite end point and normalized RVD improved clinical outcomes of baseline RVD. Predictors of new-onset RVD included a higher Society of Thoracic Surgeons score, larger left ventricular end-diastolic volume, lower left ventricular ejection fraction, higher systolic pulmonary artery pressure and smaller RV base diameter. Conclusions: Changes in periprocedural RVD status significantly affect the risk stratification outcomes after TAVR. Therefore, they may be used as part of decision-making and risk assessment strategies. Clinical Trial Registration: ClinicalTrials.gov Protocol Registration System (NCT02917980).

Navigating Pediatric Cor Pulmonale: A Comprehensive Review of Diagnosis and Management.

Pediatric cor pulmonale, characterized by right ventricular dysfunction due to chronic pulmonary hypertension, presents significant diagnostic and management challenges. This comprehensive review delves into this complex condition's etiology, clinical presentation, diagnostic strategies, and management. Key etiological factors include congenital heart defects, chronic lung diseases, and pulmonary vascular disorders. Early diagnosis, facilitated by imaging, hemodynamic assessments, and laboratory investigations, is crucial for effective intervention. Pediatric cor pulmonale management encompasses pharmacological treatments, such as vasodilators, diuretics, and inotropic agents, and non-pharmacological interventions, including oxygen therapy, mechanical ventilation, and surgical options. Long-term follow-up is essential to monitor disease progression and adjust treatment strategies accordingly. Multidisciplinary care involving pediatric cardiologists, pulmonologists, and critical care specialists is paramount to address the multifaceted needs of these patients. The review highlights the importance of early recognition and comprehensive care, offering insights into current best practices and future research and clinical practice directions. Advances in understanding the pathophysiology of pediatric cor pulmonale and emerging therapies promise to improve patient outcomes, underscoring the need for continued collaboration and innovation in this field.

Assessment of right ventricular systolic function using speckle tracking strain imaging in patients with severe tricuspid regurgitation: a validation study with cardiac magnetic resonance.

BACKGROUND: Right ventricular (RV) systolic dysfunction is an established prognostic factor in patients with severe tricuspid regurgitation (TR). However, accurate assessment of RV systolic function using conventional echocardiography remains challenging. We investigated the accuracy of strain measurement using speckle tracking echocardiography (STE) for evaluating RV systolic function in patients with severe TR. METHODS: We included consecutive patients with severe TR who underwent echocardiography and cardiac magnetic resonance imaging (CMR) within 30 days between 2011 and 2023. Two-dimensional STE was used to measure RV free wall longitudinal strain (RVFWLS) and global longitudinal strain (RVGLS). These values were compared with the RV ejection fraction (RVEF) from CMR. RV systolic dysfunction was defined as a CMR-derived RVEF < 35%. RESULTS: A total of 87 patients with severe TR were identified during the study period. Among echocardiographic RV strain measurements, RVFWLS was the best correlate of CMR-derived RVEF (r = -0.37, P < 0.001), followed by RVGLS (r = -0.27, P = 0.012). Receiver operating characteristic (ROC) curve analysis revealed that RVFWLS provided better discrimination of RV systolic dysfunction, yielding an area under the ROC curve (AUC) of 0.770 (95% confidence interval [CI], 0.696-0.800) than RV fractional area change (AUC, 0.615; 95% CI, 0.500-0.859). CONCLUSIONS: In patients with severe TR, STE-derived RVFWLS showed the best correlation with RVEF on CMR and displayed superior discrimination of RV systolic dysfunction compared with the RV fractional area change. This study suggests the potential usefulness of STE in assessing RV systolic function in this population.

Right ventricular dysfunction in the critically ill. Echocardiographic evaluation.

Right ventricular dysfunction is common in critically ill patients, and is associated with increased mortality. Its diagnosis moreover remains challenging. In this review, we aim to outline the potential mechanisms underlying abnormal biomechanics of the right ventricle and the different injury phenotypes. A comprehensive understanding of the pathophysiology and natural history of right ventricular injury can be informative for the intensivist in the diagnosis and management of this condition, and may serve to guide individualized treatment strategies. We describe the main recommended parameters for assessing right ventricular systolic and diastolic function. We also define how to evaluate cardiac output and pulmonary circulation pressures with echocardiography, with a focus on the diagnosis of acute cor pulmonale and relevant applications in critical disorders such as distress, septic shock, and right ventricular infarction.

Septic cardiomyopathy phenotype in the critically ill may depend on antimicrobial resistance.

Background: Sepsis is a life-threatening organ dysfunction, and septic cardiomyopathy (SCM) may complicate the course of the disease. Infection with multidrug-resistant (MDR) pathogens has been linked with worse outcomes. This study aims to evaluate SCM in patients with infections caused by different antimicrobial-resistant phenotypes. Method: This retrospective study included patients with sepsis/septic shock, hospitalized, and intubated in the intensive care unit of the University Hospital of Larissa between January 2022 and September 2023 with echocardiographic data during the first two days after infection onset. The patients were divided into two groups: non-MDR-SCM group and MDR-SCM group. The cardiac function was compared between the two groups. Result: A total of 62 patients were included in the study. Forty-four patients comprised the MDR-SCM and 18 the non-MDR-SCM group. Twenty-six patients (41.9%) presented with left ventricular (LV) systolic dysfunction, and ≤35% right ventricular fractional area change (RVFAC) was present in 56.4%. LV systolic function was more severely impaired in the non-MDR-SCM group (left ventricular ejection fraction, 35.8% ±4.9% vs. 45.6%±2.4%, P=0.049; LV outflow tract velocity time integral, [10.1±1.4] cm vs. [15.3±0.74] cm, P=0.001; LV-Strain, -9.02%±0.9% vs. -14.02%±0.7%, P=0.001). The MDR-SCM group presented with more severe right ventricular (RV) dilatation (right ventricular end-diastolic area/left ventricular end-diastolic area, 0.81±0.03 vs. 0.7±0.05, P=0.042) and worse RV systolic function (RVFAC, 32.3%±1.9% vs. 39.6%±2.7%, P=0.035; tricuspid annular plane systolic excursion, [15.9±0.9] mm vs. [18.1±0.9] mm, P=0.165; systolic tissue Doppler velocity measured at the lateral tricuspid annulus, [9.9±0.5] cm/s vs. [13.1±0.8] cm/s, P=0.002; RV-strain, -11.1%±0.7% vs. -15.1%±0.9%, P=0.002). Conclusion: SCM related to MDR infection presents with RV systolic dysfunction predominance, while non-MDR-SCM is mainly depicted with LV systolic dysfunction impairment.

Unlocking the Therapeutic Symphony: A Systematic Review Exploring the Role of Levosimendan in the Management of Heart Failure.

Levosimendan, a novel drug, a calcium-sensitizing inotrope, has emerged as a potential therapeutic modulator for heart failure (HF). This review appraises the efficacy and safety of levosimendan in managing HF, in different clinical settings. The study aims to examine the clinical outcomes reported in the selected trials to determine the effectiveness of levosimendan in improving key parameters related to HF. Seven relevant studies encompassing 1200 participants were identified from three databases. Inclusion criteria included clinical trials that investigated the therapeutic efficacy of levosimendan in the treatment of HF, and studies involving both adult and pediatric participants. Exclusion criteria involved studies with insufficient data, studies other than clinical trials, case reports, letters to the editor, conference papers, grey literature, and studies published in a language other than English. Upon evaluating the included studies, it was found that levosimendan shows improved hemodynamics and clinical efficacy in patients with severe septic cardiomyopathy. Levosimendan enhanced right ventricular (RV) function in patients with RV dysfunction after mitral valve (MV) surgeries and decreased the amount of N-terminal pro-B-type natriuretic peptide (NT-ProBNP) in non-ST elevated myocardial infarction (NSTEMI) patients with elevated NT-proBNP, all without increasing the overall cost or duration of hospitalization. Despite variations in study designs and participant characteristics, evidence suggests levosimendan significantly improves left ventricular ejection fraction (LVEF) and exercise tolerance measured by a six-minute walk distance. Notably, its safety profile appears favorable with minimal arrhythmic events and comparable rates of adverse effects to a placebo. This systematic review highlights levosimendan's promising potential for HF management, warranting further research to solidify its clinical role.

Interventricular septum involvement is related to right ventricular dysfunction in anterior STEMI patients without right ventricular infarction: a cardiovascular magnetic resonance study.

The value of cardiovascular magnetic resonance (CMR) in assessing and predicting acute right ventricular (RV) dysfunction in patients with anterior ST-segment elevation myocardial infarction (STEMI) remains ascertained. Eighty eight patients with anterior STEMI were prospectively recruited and underwent CMR examinations within one week following the coronary intervention. Patients with RV ejection fraction (RVEF) less than 2 standard deviations below the average at the center (RVEF ≤ 45.0%) were defined as having RV dysfunction. The size of infarction, segmental wall motion, and T1 and T2 mapping values of global myocardium and the interventricular septum (IVS) were measured. Predictive performance was calculated using receiver-operating characteristic curve analysis and logistic regression test. Twenty two patients presented with RV dysfunction. The RV dysfunction group had a larger IVS infarct extent (54.28 ± 10.35 vs 33.95 ± 15.09%, P < 0.001) and lower left ventricle stroke volume index (33.93 ± 7.96 vs 42.46 ± 8.14 ml/m2, P < 0.001) compared to the non-RV dysfunction group. IVS infarct extent at 48.8% best predicted the presence of RV dysfunction with an area under the curve of 0.864. Left ventricular stroke volume index (LVSVI) and IVS infarct extent were selected by stepwise multivariable logistic regression analysis. Lower LVSVI (odds ratio [OR] 0.90; 95% confidence interval [CI], 0.79 to 0.99; P = 0.044) and higher IVS infarct extent (OR 1.16; 95% CI 1.05 to 1.33; P = 0.01) were found to be independent predictors for RV dysfunction. In patients with anterior STEMI, those with larger IVS infarct extent and worse LV function are more likely to be associated with RV dysfunction.

Cancer Therapy-Associated Pulmonary Hypertension and Right Ventricular Dysfunction: Etiologies and Prognostic Implications.

Advances in cancer therapies have improved oncologic outcomes but can potentially expose patients to risk of cardiovascular toxicity. While left ventricular (LV) dysfunction is a well-known cardiotoxicity of cancer therapy. Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are seen with several cancer therapies, including alkylating agents, tyrosine kinase inhibitors (TKIs), and immunotherapy, and are associated with significant morbidity and mortality. Awareness and recognition of cancer therapy-associated PH and RV dysfunction is critical to identify underlying etiologies and institute the appropriate therapy. However, gaps exist in the current literature on the epidemiology of PH and RV dysfunction in cancer, underlying pathophysiology and optimal management strategies.

Right ventricular dysfunction: pathophysiology, experimental models, evaluation, and treatment.

Interest in the right ventricle has substantially increased due to advances in knowledge of its pathophysiology and prognostic implications across a wide spectrum of diseases. However, we are still far from understanding the multiple mechanisms that influence right ventricular dysfunction, its evaluation continues to be challenging, and there is a shortage of specific treatments in most scenarios. This review article aims to update knowledge about the physiology of the right ventricle, its transition to dysfunction, diagnostic tools, and available treatments from a translational perspective.

Exploring the inflammation-related mechanisms of Lingguizhugan decoction on right ventricular remodeling secondary to pulmonary arterial hypertension based on integrated strategy using UPLC-HRMS, systems biology approach, and experimental validation.

BACKGROUND: Pulmonary arterial hypertension (PAH) and the consequent right heart dysfunction persist with high morbidity and mortality, and the mechanisms and pharmacologic interventions for chronic right-sided heart failure (RHF) have not been adequately investigated. Research has shown that prolonged inflammation is critical in precipitating the progression of PAH-associated right heart pathology. Some research demonstrated that Lingguizhugan decoction (LGZGD), as a classical Chinese medicine formula, had beneficial effects in alleviating PAH and RHF, while its underlying mechanisms involved are not fully elucidated. PURPOSE: Based on that, this study aims to investigate the effects and underlying mechanisms of LGZGD on PAH-induced RHF. STUDY DESIGN: In this study, we identified the serum constituents and deciphered the potential anti-inflammatory mechanism and crucial components of LGZGD using combined approaches of UPLC-HRMS, transcriptomic analysis, and molecular docking techniques. Finally, we used in vivo experiments to verify the expression of key targets in the monocrotaline (MCT)-induced RHF model and the intervene effect of LGZGD. RESULTS: Integrated strategies based on UPLC-HRMS and systems biology approach combined with in vivo experimental validation showed that LGZGD could improve right heart fibrosis and dysfunction via regulating diverse inflammatory signaling pathways and the activity of immune cells, including chemokine family CCL2, CXCR4, leukocyte integrins family ITGAL, ITGB2, and M2 macrophage infiltration, as well as lipid peroxidation-associated HMOX1, NOX4, and 4-HNE. CONCLUSION: The present research demonstrated for the first time that LGZGD might improve PAH-induced RHF through multiple anti-inflammatory signaling and inhibition of ferroptosis, which could provide certain directions for future research in related fields.

Risk factors and prognostic analysis of right ventricular dysfunction after lung resection for NSCLC.

Objectives: Lung cancer is the leading cause of cancer death, and 80-85% of all lung cancer cases are non-small cell lung cancer (NSCLC). Surgical resection is the standard treatment for early-stage NSCLC. However, lung resection, a surgical procedure, can result in complications and increased mortality. Recent studies have shown a significant correlation between complications after lung resection and right ventricular dysfunction. Methods: Transthoracic echocardiography-derived right ventricular-pulmonary artery coupling (RV-PAC) was utilized to assess right ventricular function in these patients. Multivariate logistic regression analysis was also conducted to assess risk factors independently associated with RV-PA uncoupling. The 3- and 5-year cumulative survival rates were estimated with Kaplan-Meier curves, and differences between groups were analyzed using the Mantel-Cox log-rank test. Results: RV-PA uncoupling was defined as a TAPSE/PASP value < 0.67 mm/mm Hg according to spline analysis. The results of multivariable logistic regression analysis indicated that diabetes is an independent risk factor for right ventricular dysfunction after lung resection in patients with NSCLC. Kaplan-Meier analysis revealed a significant decrease in the survival rate of patients with RV-PA uncoupling at both the 3-year follow-up (73% vs 40%, p < 0.001) and 5-year follow-up (64% vs 37%, p < 0.001). Conclusions: After lung resection for NSCLC, the patient's right ventricular function predicts prognosis. Patients with right ventricular dysfunction, particularly those with diabetes mellitus, have a worse prognosis. It is crucial to actively prevent and correct risk factors to reduce the mortality rate in these patients.

Can central venous pressure help identify acute right ventricular dysfunction in mechanically ventilated critically ill patients?

OBJECTIVE: To investigate the relationship between central venous pressure (CVP) and acute right ventricular (RV) dysfunction in critically ill patients on mechanical ventilation. METHODS: This retrospective study enrolled mechanically ventilated critically ill who underwent transthoracic echocardiographic examination and CVP monitoring. Echocardiographic indices including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tricuspid lateral annular systolic velocity wave (S') were collected to assess RV function. Patients were then classified into three groups based on their RV function and presence of systemic venous congestion as assessed by inferior vena cava diameter (IVCD) and hepatic vein (HV) Doppler: normal RV function (TAPSE ≥ 17 mm, FAC ≥ 35% and S' ≥9.5 cm/sec), isolated RV dysfunction (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD ≤ 20 mm or HV S ≥ D), and RV dysfunction with congestion (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD > 20 mm and HV S < D). RESULTS: A total of 518 patients were enrolled in the study, of whom 301 were categorized in normal RV function group, 164 in isolated RV dysfunction group and 53 in RV dysfunction with congestion group. Receiver operating characteristic analysis revealed a good discriminative ability of CVP for identifying patients with RV dysfunction and congestion(AUC 0.839; 95% CI: 0.795-0.883; p < 0.001). The optimal CVP cutoff was 10 mm Hg, with sensitivity of 79.2%, specificity of 69.4%, negative predictive value of 96.7%, and positive predictive value of 22.8%. A large gray zone existed between 9 mm Hg and 12 mm Hg, encompassing 95 patients (18.3%). For identifying all patients with RV dysfunction, CVP demonstrated a lower discriminative ability (AUC 0.616; 95% CI: 0.567-0.665; p < 0.001). Additionally, the gray zone was even larger, ranging from 5 mm Hg to 12 mm Hg, and included 349 patients (67.4%). CONCLUSIONS: CVP may be a helpful indicator of acute RV dysfunction patients with systemic venous congestion in mechanically ventilated critically ill, but its accuracy is limited. A CVP less than10 mm Hg can almost rule out RV dysfunction with congestion. In contrast, CVP should not be used to identify general RV dysfunction.