The Right Heart: Ignored and Almost Forgotten

“Thus the right ventricle may be said to be made for the sake of transmitting blood through the lungs, not for nourishing them.” With this statement in 1616, Sir William Harvey is considered to be the first who described the importance of right ventricle in his seminal treatise, De Motu Cordis.[1] Although this was written more than 400 years ago, the importance of the right ventricle (RV) was ignored and it became, as Ziesenitz put it, “the neglected ventricle.”[2]

What do we know for sure about the right ventricle? Are we familiar with the fact that coronary perfusion of the right heart is different than of the left? The right coronary artery is perfused during systole[3]! How do we assess right ventricular function? Is tricuspid annular plane systolic excursion (TAPSE), among other echocardiographic parameters, the way to go, or speckle tracking echo, or magnetic resonance tomography (MRT)? As the right ventricle is of increasing interest nowadays, we are challenged with more unknowns than knowns. We will leave these unanswered questions to physiologists and cardiologists and stick to more surgical aspects.

Over the past decades, every once in a while, the right heart as a whole, tricuspid valve, and/or pulmonary valve surgery becomes the focus of our specialty. For instance, we learned about the importance of the right heart with the beginning of heart transplantations. Griepp et al published an article in the 1970s dealing with the problem of RV failure in heart transplant recipients. As a matter of fact, more than 40 years later, we are still debating the same problem.[4]

At this point, I would strongly recommend reading the introduction of Anastasiadis et al in their book, “The Failing Right Heart,”[5] and while you are at it, read the entire book. The authors thoroughly explain the failing right heart and also go into the details regarding the differences between RV and LV. The RV and LV originate from different embryological sources, thus explaining differences in energy metabolism, contractile elements, remodeling of the extracellular matrix, calcium handling, and cardiac muscle tissue development.[6]

Carpentier et al published their landmark article, “A new reconstructive operation for correction of mitral and tricuspid insufficiency,” introducing the concept of a rigid ring annuloplasty.[7] De Vega published his technique in those years as well.[8] Carpentier finally became the godfather of atrioventricular valve reconstructive surgery with his “French correction” article in the 1980s.[9] I believe most surgeons spent time in one or more “Club mitrale” meetings. At that time, we had already read the first randomized study comparing those two techniques.[10] Although this study revealed better results for a ring annuloplasty, the debate is still going strong. Today, we still argue about De Vega's technique, different rings, and a variety of bands. You will find some of that in this issue.

Likewise, we saw the introduction of “neo chords” by David.[11] This argument is actually debated under the headline “Respect or Resect” (let me add, “Respect and/or Resect”), mainly focusing, however, on the mitral valve.

In the 2000s, Dreyfus et al published his thoughts on tricuspid regurgitation.[12] Annular dilatation is not reversible and is the risk factor for tricuspid insufficiency. If you see dilatation, you have to treat it.[13] This triggered again an up-to-the-minute debate with David being the adversary.[14]

This issue of the Thoracic and Cardiovascular Surgeon (ThCVS) wants to provide an overview of surgical treatment options for etiologically different diseases of the right heart. This, in combination with the book by Anastasiadis et al, should bring the interested cardiac surgeon up-to-date.

• References

• 1 Harvey W. Excerctatio Anatomica de Motu Cordis et Sanguinis in Animalibus. Fracofurti Guilielem Fitzeri, 1628, translated by C.D. Leake. Springfield: Charles C Thomas; 1928
• 2 Ziesenitz V, Köhler D, Gorenflo M. The failing right heart: the neglected ventricle?. Clin Pharmacol Ther 2014; 96: 302-393
• 3 Pape HC, Kurtz A, Silbernagl S. Physiologie. Stuttgart: Thieme; 2010: 143
• 4 Griepp RB, Stinson EB, Dong Jr E, Clark DA, Shumway NE. Determinants of operative risk in human heart transplantation. Am J Surg 1971; 122 (02) 192-197
• 5 Anastasiadis K, Westaby S, Antonitis P. The Failing Right Heart. Switzerland: Springer; 2015
• 6 Friehs I, Cowan DB, Choi YH. , et al. Pressure-overload hypertrophy of the developing heart reveals activation of divergent gene and protein pathways in the left and right ventricular myocardium. Am J Physiol Heart Circ Physiol 2013; 304 (05) H697-H708
• 7 Carpentier A, Deloche A, Dauptain J. , et al. A new reconstructive operation for correction of mitral and tricuspid insufficiency. J Thorac Cardiovasc Surg 1971; 61 (01) 1-13
• 8 De Vega NG. Selective, adjustable and permanent annuloplasty. An original technic for the treatment of tricuspid insufficiency [Article in Spanish]. Rev Esp Cardiol 1972; 25 (06) 555-556
• 9 Carpentier A. Cardiac valve surgery--the “French correction”. J Thorac Cardiovasc Surg 1983; 86 (03) 323-337
• 10 Rivera R, Duran E, Ajuria M. Carpentier's flexible ring versus De Vega's annuloplasty. A prospective randomized study. J Thorac Cardiovasc Surg 1985; 89 (02) 196-203
• 11 David TE. Replacement of chordae tendineae with expanded polytetrafluoroethylene sutures. J Card Surg 1989; 4 (04) 286-290
• 12 Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?. Ann Thorac Surg 2005; 79 (01) 127-132
• 13 Dreyfus GD, Martin RP, Chan KM, Dulguerov F, Alexandrescu C. Functional tricuspid regurgitation: a need to revise our understanding. J Am Coll Cardiol 2015; 65 (21) 2331-2336
• 14 David TE, David CM, Fan CS, Manlhiot C. Tricuspid regurgitation is uncommon after mitral valve repair for degenerative diseases. J Thorac Cardiovasc Surg 2017; 154 (01) 110-122.e1