Right heart pathology most frequently manifests as right ventricular failure (RVF). The two widely used terms of right versus left ventricle failure refer to the two clinical syndromes where pulmonary versus systemic congestion dominate. The concept of congestive heart failure refers to global heart failure, comprising both systemic and pulmonary venous stasis (congestion). The term ‘cor pulmonale’ is popular, however, currently, it has no consensual definition, and it seems more appropriate to define this condition by the presence of pulmonary hypertension (PH) resulting from diseases affecting the structure and/or the function of the lungs: PH results in right ventricular enlargement and may lead, with time, to right heart failure (RHF) (Weitzenblum et al. 2009).
Right heart failure can occur in the development of left sided heart failure, in this case leading to global heart failure, or can occur separately, as in the case of primary pulmonary hypertension, pericarditis, left to right shunt (atrial septal defect, ventricular septal defect, anomalous pulmonary venous return), Eisenmenger syndrome, pulmonary embolism, mitral stenosis, stenosis of the pulmonic valve or pulmonary artery. Other examples of right ventricular diseases include right ventricular myocardial infarction and various types of cardiomyopathy affecting the right ventricle. Chronic obstructive pulmonary disease (COPD) is the most common cause of cor pulmonale, while idiopathic pulmonary fibrosis and the obesity-hypoventilation syndrome are much less frequent ethyologies (Weitzenblum et al. 2009).
Right ventricular (RV) failure is therefore a complex clinical syndrome that can result from any structural or functional cardiovascular disorder that impairs the ability of the RV to fill or to eject blood. The cardinal clinical manifestations of RV failure are: (a) fluid retention, which may lead to peripheral edema, ascites, and anasarca; (b) decreased systolic reserve or low cardiac output, which may lead to exercise intolerance and fatigue; or (c) atrial or ventricular arrhythmias. RV dysfunction, on the other hand, refers to abnormalities of filling or contraction without reference to signs or symptoms of heart failure (HF) (Haddad et al. 2008).
History taking and the clinical examination still remain key diagnostic elements and are augmented by a series of paraclinical tests that help to accurately establish etiology and classify severity. In general, when addressing the clinical manifestations of the right heart pathology, we consider two distinct categories of patients: those with an acute presentation (pulmonary embolism, RV infarction, arrhythmogenic RV dysplasia), and those with chronic pulmonary arterial hypertension (PAH) who develop RV failure (Matthews et al. 2008). Chronic pulmonary hypertension develops over weeks to months, and leads to RV concentric hypertrophy, without inflammation, that may progress slowly to RV failure. In contrast, pulmonary embolism (PE) results in an abrupt vascular occlusion leading to increased pulmonary artery pressure within minutes to hours, which causes immediate deformation of the RV. Right ventricular injury is secondary to mechanical stretch, shear force, and ischemia that together provoke a cytokine and chemokine-mediated inflammatory phenotype that amplifies injury (Watts et al. 2010).
The approach to the patient with known or suspected right heart pathology begins with a directed history and targeted physical examination, the scope of which depends on the clinical context at the time of presentation. In those presenting for a routine check-up, a more detailed or thorough examination may be conducted, whilst in the case of patients presented at the emergency room, a more focused approach should be taken. When taking past medical history it is very important to inquire about the presence of coronary artery disease, emphysema/ chronic bronchitis, history of deep venous thrombosis, recurrent abortions, autoimmune diseases, and infections.
Right ventricular failure shows signs and symptoms which are distinct from those seen in the case of left ventricular failure. Most patients may display clinical findings which easily clarify the diagnosis; however, the elderly may prove paucisymptomatic showing only atypical manifestations such as asthenia, abdominal discomfort or obnubilation. Conversely, in those with typical findings, such as dyspnoea and oedema, the underlying etiology may prove to be lung disease, chronic venous insufficiency, or obesity, in the absence of significant cardiac disease.
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