Myocardial Oedema and Congestive Heart Failure: One Piece of the Puzzle?

Therapeutic management of patients with congestive heart failure, independent of left ventricular ejection fraction, is one of the main challenges in clinical practice. Highlighting unrecognized factors that contribute to the deterioration of this medical condition is of outstanding importance. Namely, right ventricular failure has been shown to have a major role as an independent prognostic determinant not only in heart failure with reduced ejection fraction but also in heart failure with preserved ejection fraction, as outlined in articles recently issued.1-4 As such, myocardial oedema might play an unrecognized role in worsening heart failure, particularly biventricular heart failure. Myocardial oedema is common in patients with congestive heart failure,5 and experimental studies have clearly established the deleterious effects of this condition on both left ventricular systolic and diastolic function.6-9 Further, some evidence is that myocardial dysfunction persists after myocardial oedema resolution.9 The main causes of myocardial oedema in patients with heart failure are pulmonary hypertension and low levels of serum protein that are mainly related to low levels of serum albumin, which induce coronary venous hypertension related to right ventricular dysfunction, and decreased serum colloid osmotic pressure, respectively.6-8 Pulmonary hypertension, right ventricular dysfunction, left ventricular myocardial dysfunction and increased left ventricular filling pressures are linked to each other through a complex and not well understood vicious circle, in which myocardial oedema is likely to play a central role. This may in part explain why pulmonary hypertension, right ventricular dysfunction, left ventricular filling pressures and hypoalbuminaemia are reported potent prognosticators in patients with heart failure, irrespective of left ventricular ejection fraction. Further clinical research is warranted to confirm the contribution of myocardial oedema to the progression of congestive heart failure, as well as the potential benefits of targeted therapeutic intervention.