From the Guidelines
A mildly dilated RV with normal RVSP warrants regular follow-up with interval echocardiography every 6-12 months to monitor for progression, as recommended by the 2018 AHA/ACC guideline for the management of adults with congenital heart disease 1. This approach is based on the principle of monitoring for signs of progressive RV dilation and/or dysfunction, which would necessitate further intervention, such as pulmonary valve replacement in cases of significant pulmonary regurgitation (PR) 1. The normal RVSP in this context is reassuring, indicating the absence of pulmonary hypertension, a condition that would significantly alter the management approach and prognosis. Key considerations in the management of such patients include:
- Assessment of PR severity and RV size/function, as outlined in the guideline 1
- Symptoms such as dyspnea, chest pain, and/or exercise intolerance referable to PR or otherwise unexplained, which would prompt a more urgent evaluation and potential intervention
- The use of imaging studies like echocardiography and possibly cardiac MRI for a more detailed assessment of RV function and structure
- Exercise testing to evaluate functional capacity and detect any signs of decreased exercise tolerance, which could indicate progressive RV dysfunction Given the current findings of mild RV dilation with normal RVSP, the focus should be on surveillance and early detection of any progression, rather than immediate intervention, unless symptoms or significant progression dictate otherwise, as per the guideline recommendations 1.
From the Research
Right Ventricle Dilatation and Normal RVSP
- A mildly dilated right ventricle (RV) with normal right ventricular systolic pressure (RVSP) can be an indicator of various conditions, including RV volume overload, RV pressure overload, RV myocardial disease, or non-pathological RV dilatation 2.
- The differential diagnosis of RV dilatation can be challenging, and echocardiographic findings, such as those obtained through transthoracic echocardiography (TTE), can be useful in assessing the underlying cause of RV dilatation 2.
- In patients with heart failure, a mildly elevated RVSP has been associated with an increased risk of hospitalization and mortality, highlighting the importance of monitoring RVSP in these patients 3.
Echocardiographic Evaluation
- Echocardiography can be used to evaluate RV function and detect signs of RV dilatation, such as increased right ventricular end-diastolic volume index (RVEDVI) or right ventricular end-systolic volume index (RVESVI) 4.
- The tricuspid annular plane systolic excursion (TAPSE) to RVSP ratio can be used to evaluate RV function and has been shown to be reduced in patients with rheumatoid arthritis, indicating worse RV function 5.
Clinical Implications
- Patients with mildly dilated RV and normal RVSP should undergo further evaluation to determine the underlying cause of RV dilatation and to assess the risk of adverse outcomes 3.
- Echocardiographic evaluation, including TTE and measurement of RV functional parameters, can be useful in assessing RV function and guiding clinical management 2, 5.