What Is Heart Failure
Heart failure means that your heart can’t pump enough oxygen-rich blood to meet your body’s needs. Heart failure doesn’t mean that your heart has stopped or is about to stop beating. But without enough blood flow, your organs may not work well, which can cause serious problems.
Heart failure can affect one or both sides of your heart:
- With right-sided heart failure, your heart is too weak to pump enough blood to your lungs to get oxygen.
- With left-sided heart failure, your heart can’t pump enough oxygen-rich blood out to your body. This happens when the left side of your heart becomes either:
- Too weak to pump enough blood.
- Too thick or stiff to relax and fill with enough blood.
Left-sided heart failure is more common than right-sided heart failure.
Left Ventricular Assist Devices
Left ventricular assist devices are mechanical pumps that can help if your left ventricle isn’t working properly and medication alone isn’t helping.
They may be used as a permanent treatment if you can’t have a heart transplant, or as a temporary measure while you wait for a transplant.
In addition to the pump, LVADs also include an external battery. A wire connecting this to the pump will need to be placed under your skin during the operation.
Read more about LVADs on the British Heart Foundation website.
Treatment Of Right Heart Failure: Is There A Solution To The Problem
Dr. Muddassir Mehmood
Dr. Theodore A. Frank
Right heart function is a significant determinant of outcomes across a variety of aetiologies of right ventricular dysfunction. Right heart failure syndrome is characterised by the inability of the right ventricle to generate sufficient stroke volume. Management often requires simultaneous execution of multiple strategies to optimise RV preload, contractility and afterload, while maintaining a favourable balance between the right- and left-sided circulations. A temporary mechanical circulatory support device can be used in refractory cases as a bridge to recovery. This article aims to outline contemporary strategies for treating right heart failure in the acute setting.
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Adaptive Vs Maladaptive Remodeling Of The Right Ventricle
Though PH remodeling is a continuum, experimental studies often differentiate ventricular remodeling into adaptive and maladaptive processes dependent on geometric and molecular characteristics. Adaptive remodeling is characterized by high mass to volume ratio , normal to mildly dilated RV size, and preserved systolic and diastolic function and VA coupling. Maladaptive remodeling is associated with RV enlargement, decreased RV systolic and diastolic function, low VA
Mechanical Circulatory Support Devices And Treating The Underlying Cause Of Right Heart Failure
Although a detailed discussion of the management of specific aetiologies of RV failure is beyond the scope of this article, the identification and management of treatable causes of RV failure is an important aspect of management strategy. Examples include thrombolytic or catheter-based management for massive pulmonary embolism and early coronary reperfusion for RV infarction.
In cases refractory to medical therapy, timely deployment of mechanical circulatory support may offer a bridge to recovery or to the definitive management of the underlying cause. Percutaneous support options include extracorporeal membrane oxygenation , which offers right- and left-sided circulatory support. Currently available options for percutaneous right ventricular assist devices include the Impella RP System , and TandemLife using the PROTEK Duo cannula. Surgically cannulated pumps such as the Levitronix CentriMag left ventricular assist system can also offer RV support when employed in a right atrial and pulmonary artery configuration. Although none of the durable ventricular assist devices is currently approved for RV support, their use has been reported. Select patients with refractory RHF may be candidates for transplantation.
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Current Therapies Available To Target The Rv In Ph
Current therapies approved for PAH target the balance between excessive vasoconstriction pathway) and lack of vasodilation pathways) in the pulmonary arterial system .
ET-1 is a potent endothelium-derived vasoconstrictor peptide which is stimulated by a variety of factors including hypoxia, growth factors, cytokines, shear stress, thrombin and angiotensin II, and acts on ETA and ETB receptors. These receptors are then blocked, causing
Other Causes Of Heart Failure Include:
- abnormal heart rhythms where your heart beats too fast, too slow or irregularly
- amyloidosis – a build-up of abnormal proteins in organs such as your heart and tissues. When it affects the heart it’s called cardiac amyloidosis – stiff heart syndrome – and can lead to heart failure
- anaemia a lack of red blood cells carrying oxygen in your blood
- congenital heart conditions different heart problems that youre born with
- endocarditis – a viral infection affecting the heart muscle
- heart valve disease – where blood struggles to flow through the heart properly, putting extra strain on the muscle
- pulmonary hypertension – raised blood pressure in the blood vessels that supply your lungs. This condition can damage the right side of your heart, leading to heart failure. Find out more about pulmonary hypertension on NHS Choices and PHA UK
- some cancer treatments, such as chemotherapy
- thyroid gland disease an underactive or overactive thyroid gland which produces too few or too many hormones
- too much alcohol .
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Will I Need A Procedure As Part Of My Left
A procedure may be necessary if:
- Your symptoms dont improve.
- Your testing or labs show signs of worsening heart failure.
Your care may include:
- Cardiac resynchronization therapy : An implantable device that uses a gentle electrical current to stimulate your hearts pumping action. Its also called a biventricular pacemaker.
- Electrical cardioversion: This procedure helps restore a normal rhythm.
- Implantable cardioverter defibrillator : This implantable device detects arrhythmias and sends a gentle electrical current to restore a normal rhythm.
- Left ventricular assist device : An implantable pump that helps the heart circulate blood.
- Heart transplant: Procedure to replace a worn-out heart with a healthy one from a donor. This treatment is for patients with the most severe forms of left-sided heart failure.
Future Research Directions In Right Ventricle Remodeling Mechanisms
The etiology of right ventricular failure in PH patients is complex and continues to be explored in current literature. Right ventricular failure depends not only on the severity of pulmonary vascular disease but also on a variety of other factors including: rate and time of onset of pulmonary hypertension, PH underlying etiology, neurohormonal activation, coronary perfusion, myocardial metabolism, and genetic and epigenetic factors , , , .
New mechanisms for RV remodeling
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Whats The Outlook For People With Right
For many people, the right combination of therapies and lifestyle changes can slow or stop the disease and improve symptoms. They can lead full, active lives.
About 1 in 10 American adults who live with heart failure have advanced heart failure. That means treatments arent working, and symptoms are getting worse. You may feel symptoms, such as shortness of breath, even when youre sitting. If you have advanced heart failure, talk with your care team about important care decisions and next steps.
What Do The Left And Right Sides Of The Heart Do
The two sides of your heart work in different ways to pump blood.
- Left side: Receives oxygen-rich blood from your lungs and delivers it to the rest of your body. The oxygen helps organs, muscles and other tissue do their job.
- Right side: Receives oxygen-poor blood from your body and delivers it to your lungs. From there, you release carbon dioxide and take in more oxygen.
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Enhancing Healthcare Team Outcomes
Right heart failure is a systemic disorder that can affect many organs and hence is best managed by an interprofessional team. The outcomes of patients with RVF is worse than those with LVF, but it does depend on the cause and other comorbidities. Patients with persistently elevated pulmonary artery pressures have the worst outcomes. Many of these patients require repeat admissions and also have prolonged stays. Despite the various therapies for RVF, the outcomes have not greatly improved over the past two decades. While heart transplant is the ideal treatment for patients with no lung pathology, the shortage of donors is a limiting factor.
Surgery And Other Procedures
If medications are not effective in managing right-sided heart failure, or if symptoms are severe, a ventricular-assist device implant or a heart transplant, may be necessary.
- Ventricular assist device surgery: This device can be implanted to help a weak heart pump more efficiently.
- Heart transplant surgery: This surgery is done when all other right-sided heart failure treatments have failed. The damaged heart is surgically removed and replaced with a healthy heart from a deceased donor.
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Pathogenesis Of Pulmonary Hypertension On The Pulmonary Vasculature
Normal pulmonary artery tone is low, but has been demonstrated to increase in tone in the setting of hypoxia or application of vasoconstrictive agents . Pulmonary artery vasodilation occurs during exercise to allow increase amount of oxygen delivery to the lungs. This tone is largely dependent on calcium balance in the smooth muscle cell . Normally, when oxygen levels are appropriate, calcium is inhibited from entering the cell secondary to hyperpolarization from potassium efflux.
Can Left Sided Heart Failure Cause Right
Yes, and the two are often linked. Left-sided heart failure results in the left ventricle having to work harder to pump blood effectively to the body which affects the right ventricles ability to pump enough blood into the lungs. Most cases of right-sided heart failure are due to complications from left-sided heart failure.
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Clinical Characteristics And Evaluation
Clinical characteristics of right-sided HF are caused by increased pressure in the right atrium and reduced left ventricular filling as a result of the effect of ventricular interdependence. Elevated central venous pressure impedes lung lymphatic drainage, so in patients with pulmonary hypertension resulting from left-sided heart diseases, lung fluid clearance decreases and excessive pulmonary edema can lead to pleural effusion.
How Is Heart Failure Diagnosed
To find out if you have heart failure, your doctor will:
- Ask about your medical history, including your symptoms
- Ask about your family health history, including relatives who have had heart failure
- Do a physical exam
In some cases, your doctor may refer you to a cardiologist for tests, diagnosis, and care.
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Pathophysiology Of Right Ventricular Dysfunction In Pulmonary Hypertension
PAH is a progressive disorder that affects both the pulmonary vasculature as well as the heart , . In animal studies, it has been demonstrated that right ventricular hypertrophy is the first sign that is acutely apparent in a right ventricle under pressure overload . Initially then the right ventricle adapts to the increased afterload by increasing its wall thickness and contractility. In most cases however, this compensation is insufficient leading to worsening right ventricle
Clinical Symptoms Of Rhf In Ph Patients
Exercise limitation is the earliest symptom of RHF and is a strong predictor of survival in PAH patients , . This is related to a decrease in cardiac output during exercise . Patients with severe PH also have an elevated incidence of arrhythmias, estimated at 12% with SVT which can contribute to exercise limitations , .
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Medicines For Heart Failure
Most people with heart failure are treated with medication. Often you’ll need to take 2 or 3 different medicines.
Some of the main medicines for heart failure include:
- SGLT2 inhibitors
You may need to try a few different medicines before you find a combination that controls your symptoms but doesn’t cause unpleasant side effects.
What Are The Current Treatment Options
The proper treatment for right-sided heart failure depends on the underlying condition causing it. Treating right-sided heart failure usually involves using one or more medications, lifestyle measures, and possibly implanted devices that support the hearts ability to pump. Treating left-sided heart failure is also important.
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Can Heart Failure Be Prevented
You may be able to prevent or delay heart failure if you:
- Work with your provider to manage any health conditions that increase your risk of developing heart failure
- Make healthy changes in your eating, exercise, and other daily habits to help prevent heart disease
NIH: National Heart, Lung, and Blood Institute
The Ticker Tapes Podcast
Anne Dixon’s life changed after discovering she had a problem with her heart when she was a student. After an operation, she went back to her normal life, but there was more in store for her. Hear her story and other real experiences from people living with her and circulatory diseases.
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Right Ventricular Myocardial Infarction
People who have a myocardial infarction caused by a blockage in the right coronary artery may suffer from damage to the right ventricular muscle, producing right-sided heart failure. Treating a right ventricular heart attack is similar to treating any myocardial infarction, including rapidly opening up the blocked blood vessel with clot-busting drugs or a stent.
However, because right-sided heart failure can limit the amount of blood that reaches the left side of the heart, drugs aimed mainly at treating left-sided ventricular weakness need to be used with great caution in people having right ventricular heart attacks.
Optimisation Of Rv Preload Afterload And Contractility
Preload optimisation
Critically ill patients may have reduced right heart preload due to volume loss, reduced venous tone from medications, sepsis or vasoplegia, and positive pressure ventilation. Although the Frank-Starling mechanism is preserved in the failing human RV myocardium , the right ventricle has a much flatter Frank-Starling curve than the left ventricle, and therefore RV contractility changes less over a wide range of filling pressures. In conditions where RV output is impaired due to contractile dysfunction but the afterload is normal , a higher preload is needed to maintain forward flow. However, the majority of conditions leading to RHF are characterised by high RV afterload. In these scenarios, reducing excessive RV preload with diuretics or haemofiltration is key to reducing RV dilatation and free wall tension, thereby minimising RV ischaemia and optimising contractility. It is generally agreed that maintaining a moderately high RV diastolic filling pressure of 8-12 mmHg is optimal in RHF. However, the goal of maintaining forward flow may be achievable at more normal filling pressures in individual cases.
Afterload reduction
Improving contractility
Concerning inotropes, in animal models low-dose dobutamine has been shown to restore RV-pulmonary artery coupling and cardiac output better than norepinephrine because of its more pronounced inotropic effect . Given that it is an inodilator, it is preferably used in normotensive patients.
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Causes And Pathophysiology Of Right Ventricular Failure
The normal RV function is an interplay between preload, contractility, afterload, ventricular interdependence and heart rhythm. Most cases of RV failure follow existing or new-onset cardiac or pulmonary diseases or a combination of both, which may increase RV afterload, reduce RV contractility, alter RV preload or ventricular interdependence or cause-related arrhythmias . To understand RV failure, it is crucial to assess these five components.
Im Concerned About My Health
You should dial 999 if you have possible heart attack symptoms or severe difficulty breathing, such as gasping for breath, choking, lips turning blue, or not being able to get words out.
If you feel like youre struggling to manage your condition at home, contact your doctor or NHS 111.
Dont delay because you think hospitals are too busy the NHS has systems in place to treat people who need urgent heart treatment. If you delay, you’re more likely to suffer serious heart damage, intensive care and spend longer in hospital.
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What Are The Stages Of Heart Failure
There are four stages or classes of heart failure. These stages describe how serious your heart failure is. When youre diagnosed, your doctor may tell you which stage you have based on your symptoms. The stages of heart failure are:
- stage 1 you dont have symptoms during everyday activity
- stage 2 – you feel normal when resting but physical activity causes symptoms
- stage 3 you feel normal when resting but a little physical activity causes symptoms
- stage 4 you cant do any physical activity without symptoms and may feel uncomfortable while resting.
What Are The Causes
Sometimes it just happens. But usually itâs left-side heart failure that causes right-side heart failure. As the left chamber of your heart loses some of its ability to pump, blood continues to back up — sometimes into your lungs.
Heart failure is a long-term condition that gets worse over time. In most cases, you get it because you have other health issues that have damaged or weakened your heart.
Some other causes of right-side heart failure include:
Coronary artery disease. This is the most common form of heart disease and cause of heart failure. When you have coronary artery disease, plaque blocks your arteries, causing blood flow to your heart muscle to slow or even stop. Read more on clogged arteries and the causes of arterial plaque.
High blood pressure. It measures how hard your heart pumps blood through your arteries. The higher your blood pressure, the harder your heart is working to pump it. That means over time, your heart muscles can thicken and weaken because of the extra work they do. Learn about the symptoms of high blood pressure.
Damaged heart valves. Valves keep blood flowing in the right direction through your heart. If they get damaged, by an infection or heart defect, for instance, your heart has to work harder to pump blood. Eventually, it will become weakened. Get more information on heart valve disease symptoms and causes.
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