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Right Ventricular Reverse Remodeling - Impact of Combination Therapy...From Midnight Insomnia to Clinical Practice

Roberto Badagliacca, MD, PhD
University of Rome Sapienza
Rome, Italy

Back to home after summertime, trying to induce sleep at night by looking at art online, I've been delighted by Magritte's Les Amants. Frustrated desires are a common theme in René Magritte's work. Here, a light veil prevents the intimate embrace between two lovers, transforming an act of passion into one of isolation and frustration. My drowsy mind immediately jumped to the tight association between pulmonary arterial hypertension (PAH) and the right ventricle (RV), where both untiring efforts on one side and hesitation on the other side have characterized the last two decades of research activities and debates. Many clinicians have been involved in the difficult task of facing the transition from imaging RV pathophysiology to its implementation and utilization in clinical practice. However, I believe we are no more than glimpsing at the tip of the iceberg, as a growing body of evidence now supports the fundamental role of the RV in PAH and the importance of imaging techniques for patients' risk assessments.

Recent studies clearly show that various therapeutic strategies may have different impacts on RV morphology and function [1,2]. Echocardiography and magnetic resonance imaging have both shown to be useful tools in clinical practice for patient evaluation describing RV morphologic and functional characteristics and their changes during follow-up. Trivial effects might be expected from oral monotherapy, while increasing effects are achieved with more aggressive approaches, as upfront double oral combination and parenteral prostanoids plus oral drugs, potentially leading to RV reverse remodeling in a similar fashion to what has been clearly established with left ventricular systolic heart failure and disease modifying therapies. Further evidence [2] seems to support the concept that RV reverse remodeling is the driven mechanism to achieve patients' clinical improvements more consistent with a low risk profile, as highlighted by international guidelines [3].

Nevertheless, some clinicians and researchers may still be aware that these interesting findings need to be validated by more robust, multi-centre studies and may have no better maxim for guiding the interpretation of the results in this setting than "look, but don't touch."

For this reason, I could be considered ingenious as Magritte was. It seems that all who see his painting are interested in the veils covering the faces of the main figures, instead of feeling the frustration of the two lovers. On the other hand, we may continue to chase multi-centre studies that will hardly come to life in recognizing the importance of RV imaging evaluation in PAH without hearing the shout behind current findings, thereby reflecting the feelings of established clinical practice.

After all, as with art, science is supposed to be inspirational, controversial, provocative and everything in between. Imaging evaluation of the RV is, in my opinion, one such painting that intrigues and provokes thought, leading to amazing findings, that like real gems lie just below the surface, hidden from view waiting to be unearthed.

Hopefully, no one will ever criticize the effectiveness of parachutes in saving lives because they have not been subjected to rigorous evaluation by using randomized controlled trials [4]. ■

Disclosure Statement: The author has no conflicts of interest to disclose.


  1. van de Veerdonk MC, Huis In T Veld AE, Marcus JT, Westerhof N, Heymans MW, Bogaard HJ, Vonk-Noordegraaf A. Upfront combination therapy reduces right ventricular volumes in pulmonary arterial hypertension. Eur Respir J. 2017 Jun 29;49(6). pii: 1700007. doi: 10.1183/13993003.00007-2017.
  2. Badagliacca R, Galiè N, Humbert M, Vachiery J-L, et al. ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J 2016;37:67-119.
  3. Smith GCS, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ?: British Medical Journal. 2003;327(7429):1459-1461.

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