What are the hemodynamic implications of biventricular vs left ventricular dysfunction in dilated cardiomyopathy?

Diopathic dilated cardiomyopathy is characterized by left ventricular (LV) systolic dysfunction. Right ventricular (RV) involvement is not a prerequisite for diagnosis. Studies have thus concentrated on left ventricular ejection fraction (LVEF) dysfunction as a determinant of symptoms, functional impairment, and prognosis. However, it recently emerged that RV performance can be an independent determinant of exercise intolerance and prognosis in heart failure due to various causes.

In a patient with dilated cardiomyopathy, it can be difficult to determine whether RV involvement is due to primary biventricular disease or is secondary to long-standing LV dysfunction as a result of pulmonary hypertension and/or ventricular interaction. In a recent retrospective study, La Vecchia et al found biventricular dysfunction in over half of 85 patients with primary dilated cardiomyopathy, confirming that it is a frequent feature if specifically sought. The characteristics associated with biventricular vs isolated LV dysfunction were a worse New York Heart Association (NYHA) functional class, lower mean blood pressure, lower mean LVEF, and greater mitral regurgitation. Surprisingly, there was no difference in disease duration or degree of pulmonary hypertension. The significant correlation between LVEF and RV systolic function suggests that the major determinant of biventricular dysfunction is LVEF, and not pulmonary hypertension.

These data confirm the notion that severe LV systolic dysfunction is associated with RV involvement, whereas milder disease is confined to the LV. This mirrors the most recent clinical and histologic data in arrhythmo-genic RV dysplasia, where the severe cases often involve both ventricles and milder disease spares the LV.

The demonstration of RV dysfunction in a patient with heart failure and LV dysfunction should trigger the suspicion of primary RV disease, given that RV dysfunction is more frequent in dilated cardiomyopathy than in ischemic heart disease for any given LVEF or pulmonary pressure value.

Keywords

pathophysiology; left ventricular dysfunction; right ventricular dysfunction; idiopathic dilated cardiomyopathy; hemodynamic parameter

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