Right Heart Dysfunction in Valvular Heart Disease

Right ventricular (RV) dysfunction is an important determinant of clinical outcomes across a wide range of cardiovascular pathologies. As the prevalence of valvular heart disease (VHD) increases with the aging population, the intersection between RV function and VHD will become all the more relevant for proper risk assessment, treatment selection, and prognostication. Even though RV dysfunction may not always be attributed to VHD, we aim to give clinicians, researchers, and regulators a deep understanding of how patients with VHD should be evaluated for RV dysfunction and treated when RV dysfunction coexists with VHD. We begin with a discussion of the epidemiology and diagnostic evaluation of RV dysfunction in patients with a variety of VHD subgroups, including right-side (ie, associated with the tricuspid valve) and left-side (ie, associated with the mitral and aortic valves) VHD. Attention is also given in that section to contemporary methods and evolving techniques for identifying and phenotyping different forms of RV dysfunction in patients with VHD. No single imaging test practically or comprehensively captures all degrees and forms of RV dysfunction in patients with VHD; therefore, the discussion emphasizes integrating evidence from different imaging modalities and hemodynamic assessments. The second component of the review discusses how RV dysfunction affects therapeutic options, including medical, transcatheter, and surgical therapies for VHD. The focus of the discussion is on the interplay between RV dysfunction in patients with right-side VHD, namely tricuspid regurgitation (TR). Unlike left-side VHD, where RV dysfunction is a marker of overall disease severity but does not necessarily indicate futility or nonresponse to therapy, right-side VHD and TR-associated RV dysfunction identifies a subset of patients where intervention may precipitate even worse RV function. The nuances of these interactions between ventricular and valvular function are the emphasis of this section, and we aim to provide a framework for understanding RV function in the context of these different forms of VHD. Finally, the review concludes with an eye to the future, discussing the ways in which RV dysfunction can be identified and managed with the use of novel techniques. This discussion is increasingly relevant as RV dysfunction and VHD frequently coexist, and accurate identification is critical to matching the right treatment for the right patient.