Assessment and diagnosis of right ventricular failure-retrospection and future directions

Abstract

The right ventricle (RV) has a critical role in hemodynamics and right ventricular failure (RVF) often leads to poor clinical outcome. Despite the clinical importance of RVF, its definition and recognition currently rely on patients' symptoms and signs, rather than on objective parameters from quantifying RV dimensions and function. A key challenge is the geometrical complexity of the RV, which often makes it difficult to assess RV function accurately. There are several assessment modalities currently utilized in the clinical settings. Each diagnostic investigation has both advantages and limitations according to its characteristics. The purpose of this review is to reflect on the current diagnostic tools, consider the potential technological advancements and propose how to improve the assessment of right ventricular failure. Advanced technique such as automatic evaluation with artificial intelligence and 3-dimensional assessment for the complex RV structure has a potential to improve RV assessment by increasing accuracy and reproducibility of the measurements. Further, noninvasive assessments for RV-pulmonary artery coupling and right and left ventricular interaction are also warranted to overcome the load-related limitations for the accurate evaluation of RV contractile function. Future studies to cross-validate the advanced technologies in various populations are required.

Keywords: assessment; future development.; knowledge gap; parameters; right ventricular failure.

Figure 1

Diagnostic flowchart of basic and advanced assessment modalities for right ventricular failure. ECG, electrocardiogram; RA, right atrial; IVC, inferior vena cava; TRV, tricuspid regurgitation velocity; PASP, pulmonary arterial systolic pressure; FAC, fractional area change; TAPSE, tricuspid annular plane systolic excursion; TDI, tissue Doppler imaging; MPI, myocardial performance index; CMR, cardiac magnetic resonance; PV, pressure–volume; Ees, end-systolic elastance; Ea, arterial elastance.

Figure 2

Electrocardiogram patterns commonly seen in right ventricular failure: (A) P pulmonale, peaked P-wave, (B) dominant R-wave in V1, (C) dominant S-wave in V5 or V6, and (D) atrial fibrillation (29, 30). Figure courtesy of Silver Heinsar, Critical Care Research Group, QLD, Australia.

Figure 3

Basic elements of the right ventricular pressure-volume loop diagram. The diagram illustrates the relationship between the pressure and the volume in the right ventricle during the 4 phases of one cardiac cycle: ventricular filling, isovolumetric contraction, ejection, and isovolumetric relaxation. Pressure–volume (PV) relationships. Connecting the end-systolic PV coordinate with the unstressed blood volume of the ventricle (volume-axis intercept—V₀), the end-systolic PV relationship (ESPVR) describes the load-independent cardiac contractility; the end-diastolic PV relationship (EDPVR) describes the load-independent ventricular diastolic function. Myocardial energetics. The sum between the stroke work (SW) described by the area within the loop and the potential space bounded within the ESPVR and EDPVR outside the loop (potential energy—PE) is called the PV area (PVA), which is linearly related to myocardial oxygen consumption. Right ventricle (RV)-pulmonary arterial (PA) coupling. The pulmonary arterial elastance (Ea) is described by the connection between the end-systolic PV coordinate with the V₀ at end-diastolic volume (V_ed). The end-systolic ventricular elastance (Ees), is described by the slope of ESPVR. The ratio between Ea and Ees (Ea/Ees) is currently the gold-standard to describe the RV-PA coupling. Figure courtesy of Silver Heinsar, Critical Care Research Group, QLD, Australia.

Figure 4

Graphical summary of the main modalities used in assessment of right ventricular failure. Created with BioRender.com. CMR, cardiac magnetic resonance; PV, pressure–volume; RV, right ventricular; PA, pulmonary artery.