Abnormal left ventricular diastolic filling in chronic thromboembolic pulmonary hypertension: true diastolic dysfunction or left ventricular underfilling?

Swaminatha V Gurudevan; Philip J Malouf; William R Auger; Thomas J Waltman; Michael Madani; Ajit B Raisinghani; Anthony N DeMaria; Daniel G Blanchard

doi:10.1016/j.jacc.2007.01.028

Abnormal left ventricular diastolic filling in chronic thromboembolic pulmonary hypertension: true diastolic dysfunction or left ventricular underfilling?

J Am Coll Cardiol. 2007 Mar 27;49(12):1334-9. doi: 10.1016/j.jacc.2007.01.028. Epub 2007 Mar 9.

Authors

Swaminatha V Gurudevan¹, Philip J Malouf, William R Auger, Thomas J Waltman, Michael Madani, Ajit B Raisinghani, Anthony N DeMaria, Daniel G Blanchard

Affiliation

¹ Division of Cardiology, University of California Irvine School of Medicine, Irvine, California, USA.

PMID: 17394966
DOI: 10.1016/j.jacc.2007.01.028

Abstract

Objectives: The purpose of this study was to investigate the cause of abnormal left ventricular (LV) Doppler diastolic filling characteristics in chronic thromboembolic pulmonary hypertension (CTEPH).

Background: In CTEPH, LV diastolic function often appears abnormal. It is unclear whether this "impaired relaxation" (E<A) filling pattern is caused by septal hypertrophy, right ventricular (RV) enlargement and LV chamber distortion, or low LV preload and underfilling.

Methods: We studied 61 patients with an E<A transmitral pattern and CTEPH who underwent pulmonary thromboendarterectomy (PTE). We compared the results of pre- and postoperative transthoracic echocardiography and right heart catheterization measurements.

Results: After PTE, mitral E velocity increased (from 54 +/- 16 cm/s to 81 +/- 20 cm/s, p < 0.001), whereas A velocity decreased (77 +/- 22 cm/s to 71 +/- 20 cm/s, p < 0.001). E/A ratio normalized (0.72 +/- 0.16 cm/s to 1.22 +/- 0.40 cm/s, p < 0.001). Pulmonary venous systolic and diastolic velocities both increased (57 +/- 13 cm/s to 68 +/- 16 cm/s and 39 +/- 15 cm/s to 70 +/- 21 cm/s, respectively, p < 0.001 for both). Diastolic velocity of the septal mitral annulus (E(m)) did not change after PTE (8.0 +/- 3.1 cm/s to 8.1 +/- 2.0 cm/s, p = ns), whereas the velocity of the lateral mitral annulus increased (9.3 +/- 3.2 cm/s to 11.8 +/- 3.1 cm/s, p < 0.001). Mean pulmonary capillary wedge pressure increased from 9.3 +/- 3.2 mm Hg to 10.6 +/- 3.8 mm Hg (p = 0.035). Despite these marked changes in LV inflow, M-mode measurements of LV septal and posterior wall thickness were normal before PTE and did not change after surgery (septal: 10 +/- 2 mm vs. 10 +/- 1 mm; posterior: 10 +/- 2 mm vs. 10 +/- 1 mm; p = NS for both comparisons).

Conclusions: The results of this study strongly suggest that the impaired relaxation pattern observed in patients with CTEPH is not solely the result of geometric effects of RV enlargement and LV chamber distortion but is caused in large part by low LV preload and relative underfilling.

Publication types

Comparative Study

MeSH terms

Adult
Aged
Chronic Disease
Diastole / physiology
Endarterectomy / methods
Female
Humans
Hypertension, Pulmonary / diagnosis
Hypertension, Pulmonary / physiopathology*
Hypertension, Pulmonary / surgery
Male
Middle Aged
Pulmonary Embolism / diagnosis
Pulmonary Embolism / physiopathology*
Pulmonary Embolism / surgery
Ventricular Dysfunction, Left / diagnosis
Ventricular Dysfunction, Left / physiopathology*
Ventricular Dysfunction, Left / surgery
Ventricular Function, Left / physiology