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European Heart Journal 2002 23(2):147-156; doi:10.1053/euhj.2001.2709
Copyright © 2002 by the European Society of Cardiology.
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Right ventricular cardiomyopathy in ß-thalassaemia major

G. Hahalis, A.S. Manolisf1, D. Apostolopoulos, D. Alexopoulos, A.G. Vagenakis and N.C. Zoumbos

Divisions of Cardiology and Hematology, Departments of Internal Medicine and Nuclear Medicine, Patras University Medical School, Patras, Greece

revised March 26, 2001; accepted March 28, 2001

Abstract

Aims To evaluate right ventricular function in patients with ß-thalassaemia major and congestive heart failure.

Background In patients with ß-thalassaemia major a high incidence of cardiac involvement still exists despite improved prognosis with chelation therapy. Development of severe right heart failure is common and has been attributed to pulmonary hypertension secondary to lung haemochromatosis. However, the possibility of direct right ventricular myocardial involvement in the absence of significant pulmonary hypertension has not been adequately investigated.

Methods Twenty-nine consecutively screened patients with ß-thalassaemia major and congestive heart failure were investigated by Doppler echocardiography, right ventricular first-pass radionuclide examination and cardiac catheterization. Haemodynamic data were obtained both before and after volume loading. A control group of 39 patients with ß-thalassaemia major, free from cardiac disease, and matched for age, gender, body surface area and heart rate was used for comparison. A subset of the control thalassaemic group (n=15) underwent both radionuclide and haemodynamic assessment.

Results The majority of patients were on non-optimal chelation therapy. Only two of 29 patients were found to have cor pulmonale. One other patient suffered from constrictive pericarditis. A restrictive filling pattern in both ventricles and left ventricular systolic dysfunction were evident in the other 26 patients. Pulmonary artery pressure (systolic, 33±8 vs 27±5mmHg, P<0·05) and pulmonary vascular resistance (114±56 vs 65±29dynes.s.cm–5, P<0·01) were only mildly elevated in the heart failure group. After volume challenge, cardiac output remained unchanged although the increments of ventricular filling pressures were significant ({Delta}right atrial: 4·8±2·2mmHg,P <0·05; {Delta}pulmonary capillary wedge: 5·6±2·9mmHg, P<0·05) and correlated with each other (r=0·69;P<0·001) in heart failure patients, suggesting pericardial constraint and ventricular interaction. In these patients compared with the control thalassaemic group, a lower right ventricular ejection fraction (29%±9 vs 59%±6, P<0·0001) without correlation with pulmonary artery pressures was found. Haemodynamically significant right ventricular dysfunction defined as mean right atrial pressure >10mmHg and ratio of mean right atrial-to-capillary wedge pressure >0·8 was evident in 15 of the 26 patients (58%), all with severe symptoms, representing three fourths of the patients in functional class III and IV. Simultaneous pressure recordings in six of these 15 patients showed equalization of ventricular end-diastolic pressures within 5mmHg.

Conclusion The majority of patients with ß-thalassaemia major and severe congestive heart failure demonstrated a unique haemodynamic pattern similar to that described in predominant right ventricular infarction, indicating severe right ventricular cardiomyopathy in addition to left ventricular dysfunction. The incidence of cor pulmonale as a cause of right heart failure seems to be much lower than previously hypothesized.

Key Words: Thalassaemia, heart failure, cardiomyopathy, right ventricle, right heart catheterization, Doppler echocardiography

f1 Correspondence: Antonis S. Manolis, Professor and Director of Cardiology, 41 Kourempana Street, Agios Dimitrios 173 43, Athens, Greece.

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