RESUMEN

En esta revisión de la disfunción ventricular derecha en tromboembolia pulmonar aguda abordamos la entidad de manera global, desde el conocimiento de la anatomía fisiológica del ventrículo derecho, la fisiopatología y su presentación clínica. Iniciamos con el estudio de la frecuencia y la mortalidad de la tromboembolia pulmonar aguda y la forma masiva. Se define la tromboembolia pulmonar masiva como causa de inestabilidad hemodinámica y su repercusión en la mortalidad. Se revisa la anatomía fisiológica del ventrículo derecho haciendo énfasis en la perfusión ventricular como un paso previo para entender el origen de la disfunción y su fisiopatología. Se menciona la clasificación de la disfunción ventricular derecha previo a la colocación de los sujetos a grupos formados de acuerdo a parámetros hemodinámicos y ecocardiográficos. Una vez definida la enfermedad, se muestra la mortalidad asociada a la disfunción y aquélla en presencia de marcadores bioquímicos de isquemia ventricular. Finalmente se menciona la presentación clínica asociada a la entidad, los signos electrocardiográficos y los ecocardiográficos más frecuentes.

PALABRAS CLAVE

Ventrículo derecho, función ventricular derecha, fisiología ventricular, isquemia ventricular derecha.

REFERENCIAS

1. Rahimtoola A, Bergin JD. Acute Pulmonary Embolism: An Update on Diagnosis and Management. Curr Probl Cardiol 2005; 30: 61-114.

2. Dalen JE, Alpert JS. Natural history of pulmonary embolism. Prog Cardiovasc Dis 1975; 17: 259-270.

3. Wood K. Major Pulmonary Embolism: Review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest 2002; 121: 1-45.

4. Dalen JE. Pulmonary embolism: What have we learned since Virchow?, Natural history, pathophysiology and diagnosis. Chest 2002; 122: 1440-1456.

5. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: Clinical Outcomes in the international cooperative pulmonary embolism registry (ICOPER). Lancet 1999; 353: 1386-1389.

6. Goldhaber SZ. Pulmonary embolism. Lancet 2004; 363: 1295-1305.

7. Kasper W, Konstantinides S, Geibel A. Management strategies and determinants of outcome in acute major pulmonary embolism: Results of a multicenter registry. J Am Coll Cardiol 1997; 30: 1165-1171.

8. Urokinasa pulmonary embolism trial. Phase 1 results: A cooperative study. JAMA 1970; 214: 2163-2172.

9. Comes KA, DeRook FA, Russel Ml, et al. The incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity. Am J Med 2000; 109: 351-356.

10. Jerjes-Sánchez C, Elizalde-González JJ, Sandoval Zárate J, Gutiérrez-FaJardo P, Seoane-García de León M, Ramírez Rivera A, et al. Diagnóstico, estratificación y tratamiento de la tromboembolia pulmonar aguda. Guías y recomendaciones del capítulo de circulación pulmonar de la Sociedad Mexicana de Cardiología. Arch Cardiol Méx. 2004; 74: S547-S585.

11. Piazza G, Goldhaber SZ. The acutely decompensated right ventricle: Pathways for diagnosis and management. Chest 2005; 128: 1836-1852.

12. McIntyre KM, Sasahara AA. The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease. Am J Cardiol 1971; 28: 288-294.

13. Barnard D. Alpert JS. Right ventricular function in health and disease. Curr Probl Cardiol 1987; I: 422-449.

14. James TN. Anatomy of the Crista Supraventricularis: Its importance for understanding right ventricular function, right ventricular infarction and related conditions. J Am Coll Cardiol 1985; 5: 1083-1095.

15. Ferlinz J. Right ventricular function in adult cardiovascular disease: Prog Cardiovasc Dis 1982; 25: 225.

16. Piene H. Pulmonary arterial impedance and right ventricular function. Physiol Rev 1986; 66: 606-652.

17. Gómez GA, Sandoval ZJ, Martínez GML, et al. Ma. Elena: La función ventricular en el neumópata. Neumol Cir Tórax 1992; 3: 21-47.

18. Vlahakes GJ, Turley K, Hoffman JIE. The pathophysiology of failure in acute right ventricular hypertension: Hemodynamic and biochemical correlations. Circulation 1981; 63: 87-95.

19. Brooks H, Kirk ES, Vokonas PS, Urschel CW, Sonnenblick EH. Performance of the right ventricle under stress:relation to right coronary flow. J Clin Invest 1971: 50: 2176-2183.

20. McIntyre KM, Sasahara AA. Hemodynamic and ventricular responses to pulmonary embolism. Prog Cardiovasc Dis 1974; 17: 175-190.

21. Santos E, Gotés J, Flores P, Ramírez S, Carrillo A, Porres M, et al. Controlled Pulmonary artery banding: A novel hydraulic device to increase right ventricular systolic pressure. Chest 2004; 126: 884S.

22. Stein M, Levy SE. Reflex and humoral responses to pulmonary embolism. Prog Cardiovasc Dis 1974; 17: 175-190.

23. Malik AB. Pulmonary microembolism. Physiol Rev 1983; 63: 114-1207.

24. Alpert JS, Godtfredsen J, Ockene IS. Pulmonary hypertension secondary to minor pulmonary embolism. Chest 1978; 73: 795-797.

25. Stein PD, Sabbah HN, Anbe DT. Performance of the failing and nonfailing right ventricle of patients with pulmonary hypertension Am J Cardiol 1979; 44: 1050-1055.

26. Calvin JE Jr. Acute right heart failure: Pathophysiology, recognition, and pharmacological management. J Cardiothorac Vasc Anesth 1991; 4: 251-265.

27. Calvin JE Jr, Baer RW, Glantz SA. Pulmonary artery constriction produces a great tight ventricular dynamic afterload than lung microvascular injury in the open chest dog. Circ Res 1985; 56: 40-56.

28. Santamore W, Dell´Italia LJ. Ventricular interdependence: Significant left ventricular contributions to right ventricular systolic function: Prog Cardiovasc Dis 1998; 40: 289-308.

29. Watanabe J, Levine MJ, Belloto F, Johnson RG, Grossman W. Effects of coronary venous pressure on left ventricular diastolic distensibility. Circ Res 1990; 67: 923-932.

30. Lowensohn HS, Khouri EM, Gregg DE, et al. Phasic right coronary artery blood flow in conscious dogs with normal and elevated right ventricular pressures. Circ Res 1976; 39: 760-766.

31. Coma-Canella I, Gamallo c, Martínez OP, et al. Acute right ventricular infarction secondary to massive pulmonary embolism. Eur Heart J 1988; 9: 534-540.

32. Azam-Khan UN, Movahed A. Pulmonary embolism and cardiac enzymes. Heart Lung 2005; 34: 142-146.

33. Hirsch LJ, Rooney MW, Wat SS, Kleinmann B, Mathru M. Norepinefrine and phenylephrine effects on right ventricular function in experimental canine pulmonary embolism. Chest 1991; 100: 796-801.

34. Prewitt RM. Hemodynamic management in pulmonary embolism and acute hypoxemic respiratory failure. Crit Care Med 1990; 18 (suppl): S61-S69.

35. Cannon CP, Goldhaber SZ. Cardiovascular risk stratification of pulmonary embolism in patients. Am J Cardiol 1996; 78: 1149-1151.

36. Goldhaber SZ. Pulmonary embolism for cardiologists. J Am Coll Cardiol 1997; 30: 1172-1173.

37. Kreit JW. The impact of right ventricular dysfunction on the prognosis and therapy of normotensive patients with pulmonary embolism. Chest 2004; 125: 1539-1545.

38. Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, et al. Short-Term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 2000; 101: 2817-2822.

39. Goldhaber SZ, Haire WD, Feldstein ML, et al. Alteplase versus heparin in acute pulmonary embolism: randomized trial assessing right-ventricular function and pulmonary perfusion. Lancet 1993; 341: 507-511.

40. Kasper W, Konstantinides S, Geibel A. Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart 1997; 77: 346-349.

41. Ribeiro A, Lindmarker P, Juhlin-Dannfelt A. Echocardiography Doppler in pulmonary embolism: Right ventricular dysfunction as a predictor of mortality rate. Am Heart J 1997; 134: 479-487.

42. Meyer T, Binder L, Hruska N. Cardiac troponin I elevation in pulmonary embolism is associated with right ventricular dysfunction. J Am Coll Cardiol 2000; 36: 1632-1636.

43. Giannitsis E, Muller-Bardorf M, Kurowski V. Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism. Circulation 2000; 102: 211-217.

44. Scridon T, Scridon C, Skali H, Alvarez A, Goldhaber SZ, Solomon SD. Prognostic Significance of troponin elevation and right ventricular enlargement in acute pulmonary embolism. Am J Cardiol 2005; 96: 303-305.

45. Lualdi JC, Goldhaber AZ. Right ventricular dysfunction after acute pulmonary embolism: Pathophysiologic factors, detection, and therapeutic implications. Am Heart J 1995; 130: 1-8.

46. Stein PD, Terrin ML, Hales CA. Clinical, laboratory, roentgenographic and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 1991; 100: 598-603.

47. Sandoval ZJ, Martínez GML, Gómez A, Palomar A, Pulido T. Tromboembolia pulmonar aguda México DF, PLAC Cardio-1 de la Sociedad Mexicana de Cardiología. Intersistemas, SA de CV 1998: 1-109.

48. Rodger MA, Carrier M, Gwynne NJ, et al. Diagnostic value of arterial blood gas measurement in suspected pulmonary embolism. Am J Respir Crit Care Med 2000; 162: 2105-2108.

49. Worsley DF, Alavi A. Radionuclide Imaging of Acute Pulmonary Embolism. Semin Nucl Med 2003; 33: 259-278.

50. McGinn S, White PD. Acute cor pulmonary resulting from pulmonary embolism. JAMA 1935; 104: 1473-1480.

51. Sreeram N, Cheriex EC, Smeets JLR. Value of the 12-lead electrocardiogram at hospital admission in the diagnosis of pulmonary embolism. Am J Cardiol 1994; 73: 298-303.

52. Punukollu G, Gowda RM, Vasavada BC, Khan IA. Role of electrocadiography in identifying right ventricular dysfunction in acute pulmonary embolism. Am J Cardiol 2005; 96: 450-452.

53. A Collaborative Study by the PIOPED Investigators. Value of the ventilation-perfusion scan in acute pulmonary embolism: Results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). JAMA 1990; 263: 2753-2759.

54. Kasper W, Meinertz T, Henkel B. Echocardiographic findings in patients with proved pulmonary embolism. Am Heart J 1986; 112: 1284-1290.

55. Kasper W, Geibel A, Tiede N, et al. Distinguishing between acute and subacute massive pulmonary embolism by conventional and Doppler echocardiography. Br Heart J 1993; 70: 352-356.

56. Pavan D, Nicolosi GL, Antonini-Canterin F, Zanuttini D. Echocardiography in pulmonary embolism disease. Intern J Cardiol 1998; 65: S87-S90.

57. Jardin F, Dubourg O, Guéret P, Delorme G, Bourdarias JP. Quantitative two-dimensional echocardiography in massive pulmonary embolism: Emphasis on ventricular interdependence and leftward septal displacement J Am Coll Cardiol 1987; 10: 1201-1206