We often joke that the right ventricle is the “forgotten ventricle,” but there is a sad truth behind this joke. Recently, there has been increased recognition of the importance of right ventricle failure and systemic congestion within some circles (e.g., nephrologists and resuscitationists). However, overall the right ventricular failure continues to be commonly overlooked.
A few examples of how right ventricular failure is ignored in everyday practice are as follows:
- An echocardiogram showing preserved LV function with RV dysfunction will often be informally described as a “normal echo.”
- I've seen some echocardiography reports with dozens of parameters describing LV function and not a single parameter investigating the right side of the heart.
- The “one-liner” used to summarize a patient's problems frequently refers to left ventricular systolic dysfunction but nearly universally omits any description of right ventricular function.
- Severe right ventricular dilation and contrast reflux on CT scans are often overlooked and not commented upon in the chart.
- Patients are often diagnosed with congestive nephropathy without any further investigation or treatment of the underlying right ventricular failure.
- Cardiology and cardiovascular critical care textbooks often have no chapter on right ventricular failure (e.g., Tubaro et al).
Ignoring right ventricular failure hurts patients. Perhaps the best example of this may be peri-intubation cardiovascular collapse. Right ventricular failure is a significant risk factor for post-intubation cardiac arrest. (35786053) Inadequately diagnosing and communicating about right ventricular failure will prevent clinicians from taking precautions when intubating these patients. Hospital electronic medical records are increasingly sophisticated about labeling patients with anatomically challenging airways. Unfortunately, in overlooking the diagnosis of right ventricular failure, we are camouflaging this group of patients with physiologically challenging airways.
Failure to properly diagnose and communicate about right ventricular failure doesn't represent a personal failure of individual practitioners, but rather it is deeply baked into the system. One example is how heart failure is classified: HFpEF, HFmrEF, or HFrEF. We communicate about heart failure patients solely in terms of their left ventricular ejection fraction.
HFpEF/HFmrEF/HFrEF classification is vaguely reminiscent of the STEMI/NSTEMI dichotomization of myocardial infarctions. These classification systems are technically accurate in a circular fashion. However, they often overlook a misclassification of the actual underlying disease states.
If we dig further into the Universal definition and classification of heart failure, we encounter this bewildering statement: (33605000)
The consensus group tasked with classifying heart failure didn't simply overlook right ventricular failure. They explicitly state that right heart failure often shouldn't be categorized as heart failure at all!
One step towards more accurate communication about right ventricular failure would be to utilize a categorization scheme that doesn't ignore the right ventricle. This could be simple and intuitive. In addition to HFrEF/HFpEF/HFmrEF we could easily add a second term to describe the right ventricle. For example, a patient with biventricular systolic failure would be classified as HFrEF-RVrEF:
Based on echocardiographic systolic parameters, right ventricular function could be classified as reduced, preserved, or moderately reduced. Would this system be perfect? Of course not. Determining RV systolic function is more complex than LV systolic function, so there could be a lively debate about exactly how to define RVrEF, RVpEF, or RVmrEF. But any mention of the right ventricle would be a step in the right direction.
Hopefully, cardiology societies' official classification of heart failure might eventually recognize RV failure and incorporate this into nomenclature – but realistically, any such change is likely decades away. In the interim, it might be reasonable for clinicians to use the above nomenclature to communicate about heart failure more comprehensively. Language changes often emerge organically from the bottom up, so perhaps this language might seep into the collective unconsciousness of medical professionals and thence into official terminology.
- PulmCrit Wee – A better classification of heart failure (HFxEF-RVxEF) - August 26, 2024
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Instead of using (say) HFrEF-RVrEF, why not commit fully to the LV/RV dichotomy, and use **LV**rEF-RVrEF instead? I understand the inclination to inherit “HF[x]EF” as a building block of your proposed terminology and to perhaps favor widespread adoption, but if we’re theorizing an ideal term, perhaps it’s worth committing all the way with precision in language.
Overall, agree with all of your points; I especially am often dismayed at a semi-commoin lack of comment on RV function on an echo report.
I agree that we need better nomenclature for this. Doing so could help how we care for patients, especially in low resource settings where indoor air quality is often worse, TB is more common, and patients are often unable to get home oxygen for chronic hypoxia. Maybe isolated RV failure gets overlooked because it falls between cardiology and pulmonology and the term “cor pulmonale” is not very descriptive. In my online textbook Integrating Ultrasound aimed at low-resource settings, I use the term isolated RV overload or “iRVO” to describe when the RV is overloaded enough to reduce LV filling and… Read more »
This article was incredibly insightful—thank you for sharing your expertise!
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