European Journal of Echocardiography 2003 4(3):226-228; doi:10.1016/S1525-2167(02)00169-5
© 2003 by European Society of Cardiology
Copyright © 2003, The European Society of Cardiology
Effect of intensive diuretic treatment over right ventricular behaviour: evidence provided from colour and pulsed-wave Doppler echocardiography
R Moreno*,
C Corros,
J Zamorano and
C Macaya
Instituto Cardiovascular, Hospital Clinico San Carlos, Madrid, Spain
* Address correspondence to: Raúl Moreno, Instituto Cardiovascular, Hospital Clinico San Carlos, Martin Lagos, s/n, 28040 Madrid, Spain. raulmorenog{at}terra.es
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Case history
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Doppler acceleration at the left ventricular outflow tract or
within the left ventricular cavity is frequent, especially in
patients with left ventricular hypertrophy
[1]. Acceleration
within the right ventricle is less common, but it has been observed
in patients with hypertrophic cardiomyopathy and right ventricle
involvement, as well as in some congenital cardiac abnormalities
[2–5].
Some mechanical adjustments in right ventricle, such as an increased ejection fraction, may compensate the reduction in venous return[6]. We present a representative case of a patient with severe left ventricular dysfunction who received an intensive treatment with diuretics, and in whom the echocardiographic study showed the features of right ventricular compensatory behaviour in response to a reduced pre-load.
A 72-year-old female patient who had suffered an anteroseptal myocardial infarction 4 years before admission was hospitalized due to decompensated heart failure and acute pulmonary oedema. The patient was treated with vasodilator agents and high doses of diuretics.
An echocardiographic study was performed 4 days after admission, when the patient was asymptomatic and without rales and other signs of cardiac failure. At the time of the echocardiographic study, blood pressure was 125/80 mmHg, heart rate 88 beats per minute, and temperature 36°C. Creatinine (0.9 mg/dl) and haemoglobin (14.8 g/dl) plasmatic values were normal; at that time, the patient was not receiving inotropic agents. Echocardiography showed a severely depressed left ventricular ejection fraction (0.19 by modified Sympsom's rule). Two-dimensional echocardiography showed a hypercontractile right ventricle, with a collapse of right ventricular cavity in systole (Fig. 1). There was no evidence of right ventricular hypertrophy by electrocardiogram or echocardiography. Four-chamber apical view showed a regional acceleration of colour Doppler flow within the right ventricular cavity; the turbulence was easily viewed in the four-chamber apical view and subcostal view (Figs. 2 and 3
). A late Doppler systolic signal in the right ventricle was obtained by the pulsed-wave Doppler (Fig. 4). There was no evidence of left ventricular volume depletion, such as respiratory variation of mitral or right ventricular inflow during diastole.
Doppler acceleration in right ventricle has been observed in
patients with hypertrophic cardiomyopathy and right ventricle
involvement, as well as in some congenital cardiac abnormalities
[2–5].
In our patient, a reflex response of right ventricular contractility
to a vigorous reduction of pre-load probably played a key role.
Other potential mechanisms, such as right ventricular hypertrophy,
interventricular septum paradox movement, and inotropic treatment,
could not be found.
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References
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- Sugishita Y., Matsuda M., Iida K., Ito I., Yamaguchi T., Koseki S. The influence of exercise on left ventricular outflow tract obstruction, left ventricular performance and electrocardiogram in hypertrophic cardiomyopathy. Acta Cardiol (1983) 38:455–471.[Web of Science][Medline]
- Mozaffarian D., Caldwell J.H. Right ventricular involvement in hypertrophic cardiomyopathy: a case report and literature review. Clin Cardiol (2001) 24:2–8.[Web of Science][Medline]
- Von Doenhoff L.J., Nanda N.C. Obstruction within the right ventricular body: two-dimensional echocardiographic features. Am J Cardiol (1983) 51:1498–1501.[CrossRef][Web of Science][Medline]
- Cazzaniga M., Azcarate M., Rico F., Fernandez L., Lopez M. Right ventricular ghost obstruction. Pediatr Cardiol (1995) 16:153–154.[CrossRef][Web of Science][Medline]
- Warembourg H., Pauchant M., Bertrand M.E., et al. Cardiomyopathies with predominant obstruction on the right ventricle. Acta Cardiol (1971) 26:526–542.[Medline]
- Guazzi M., Pepi M., Maltagliati A., Celeste F., Muratori M., Tamborini G. How the two sides of the heart adapt to graded impedance to venous return with head-up tilting. J Am Coll Cardiol (1995) 26:1732–1740.[Abstract]
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