Anne-Marie Koop

1 13 Figure 1 . Relative increases in aorta versus pulmonary artery pressure in case of increasing afterload. Vonk Noordegraaf et al. JACC 2017. The term “cardiac dysfunction” often refers to systolic dysfunction. However, also diastolic function significantly affects cardiac function. RV diastolic dysfunction not only reduces stroke volume, but is also an important indicator of outcome. 24–26 Furthermore, because of the emergence of asynchronic contraction of the ventricles, the synergy of the RV with the LV will be lost. 27 In response to increased ventricular load, the RV is able to increase contractility four to five times to meet the increased afterload conditions with preservation of ventriculoarterial coupling. Moreover, in progressive RV disease the ventricular thickening will be halted and RV dilatationwill occur. This dilatation attempts to retain stroke volume (SV) and, together with increase of heart rate, to maintain adequate cardiac output, but will eventually lead to ventriculoarterial uncoupling. 23,28 Ventriculoarterial uncoupling reflects the imbalance between the myocardial oxygen consumption and mechanical energy, 29 eventually leading to right sided heart failure. Right ventricular remodelling RV remodelling includes the presence of hypertrophy, altered angiogenesis and fibrosis. 30–33 In conditions of increased pressure load, the initial response will be the development of concentric hypertrophy, which will progress towards eccentric hypertrophy (dilatation) in case of persistent abnormal loading. 34,35 Concentric hypertrophy (wall thickening) aims to reduce wall stress and preserves the force development of theventricle, 23 butwilleventually lead todiminisheddiastolic function and contribution to Right ventricular remodelling processes aim to withstand the Right ventricular diastolic function is still insufficiently considered clinical practice and scientific research, while it is an important indicator of outcome.