Main points of RHF; cardiac embryogenesis; right ventricular (RV) geometry; relationship of RV and LV stroke volumes to increases in afterload; RV pressure-volume loops; ventricular interdependence in right-sided heart failure...
Evaluation and Management of Right-sided Heart Failure PGS TS Phạm Nguyễn Vinh Bệnh viện Tim Tâm Đức Đại học Y khoa Phạm Ngọc Thạch Đại học Y khoa Tân Tạo Viện Tim Tp HCM Khảo sát điều trị Suy tim phải Main points of RHF ❖Causes: ‐ RV cardiomyopathy ‐ RV myocardial ischemia/infarction ‐ RV volume overload caused by CHD or VHD ‐ RV pressure overload caused by PS or PH ❖Acute RHF: ‐ Unstable hemodynamics ‐ Leading mortality cause of massive PE ‐ RV myocardial infarction ‐ Shock after pericardiotomy/cardiac surgery hinhanhykhoa.com Khảo sát điều trị Suy tim phải Main points of RHF (cont.) ❖Chronic RHF: ‐ Decreased functional capacity ‐ Exercise intolerance ‐ Decreased cardiac output ‐ Progressive injury of target organs ‐ Cachexia ‐ Increased systemic inflammation Khảo sát điều trị Suy tim phải Cardiac embryogenesis ▪ Primary heart field (from Mesoderm) → Heart tube ▪ Heart tube: ➢ Atria ➢ Ventricles ▪ Secondary heart field → arterial and venous poles Konstam MA, et al Circulation 2018;137:e578–e622 Khảo sát điều trị Suy tim phải Right ventricular (RV) geometry Normal subject P: Pulmonary valve T: Tricuspid valve Chronic volume or pressure overload Konstam MA, et al Circulation 2018;137:e578–e622 Khảo sát điều trị Suy tim phải Relationship of RV and LV stroke volumes to increases in afterload Konstam MA, et al Circulation 2018;137:e578–e622 Khảo sát điều trị Suy tim phải RV pressure-volume loops ESPVR : End-systolic pressure volume relationship Ees: end-systolic elastance Loop C: decompensated hypertensive RV Konstam MA, et al Circulation 2018;137:e578–e622 Khảo sát điều trị Suy tim phải Ventricular interdependence in right-sided heart failure RV is constrained by the pericardium (arrows) Konstam MA, et al Circulation 2018;137:e578–e622 Khảo sát điều trị Suy tim phải Pathophysiology of right-sided heart failure LVEDP: left ventricular end-diastolic pressure RVEDD: right ventricular end-diastolic dimension RAP: right atrial pressure Konstam MA, et al Circulation 2018;137:e578–e622 Khảo sát điều trị Suy tim phải Hemodynamics in progressive pulmonary vascular disease PAP: Pulmonary arterial pressure; CO: cardiac output; MPAP: mean PAP; PCWP: pulmonary artery capillary wedge pressure; PVR: pulmonary vascular resistance; RAP: right atrial pressure Konstam MA, et al Circulation 2018;137:e578–e622 hinhanhykhoa.com 10 Khảo sát điều trị Suy tim phải Pathophysiology of cardiorenal disease (Acute decompensated HF leading to kidney injury) CO: cardiac output; CVP: central venous pressure; LVEDP: left ventricular enddiastolic pressure; RAAS: renin-angiotensinaldosterone system; SNS: sympathetic nervous system; SV: stroke volume Kiernan MS, et al UpToDate, January 30, 2018 21 Khảo sát điều trị Suy tim phải Clinical manifestation of RHF ❖Acute RHF: ‐ Acute RV dilatation ‐ Signs of hypoperfusion and hypotension (diaphoresis, listlessness, cyanosis, cool extremities, hypotension, and tachycardia) ‐ Shortness of breath, atrial and ventricular arrhythmias ❖Chronic RHF: ‐ Cardiorenal syndrome ‐ Cardiohepatic syndrome ‐ Gastrointestinal involvement 22 Khảo sát điều trị Suy tim phải Evaluation of RHF ❖Physical examination ❖ECG ❖Serum markers: ‐ Transaminases ‐ ↓ Albumin ‐ ↑ INR ‐ ↑ Bilirubin ❖Echocardiography ❖Cardiac MRI ❖MSCT ❖Radionuclide Imaging ❖Chest X-ray ❖Biomarkers/RV function: NT-ProBNP, BNP 23 Khảo sát điều trị Suy tim phải Hemodynamic Assessment of RH Function Hemodynamic Parameters Associated With RV Function Variable Calculation Thresholds associated with Clinical Events in Specific Populations RAP RAP (or CVP) > 15 mmHg (RHF after LVAD) Right-to-left discordance of filling pressures RAP:PCWP > 0.63 (RHF after LVAD) > 0.86 (RHF in acute MI) PA pulsatility index (PASP−PADP)/RAP