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CLINICAL RESEARCH: LV FUNCTION IN PULMONARY HYPERTENSION

Abnormal Left Ventricular Diastolic Filling in Chronic Thromboembolic Pulmonary Hypertension

True Diastolic Dysfunction or Left Ventricular Underfilling?

Swaminatha V. Gurudevan, MD^_*, Philip J. Malouf, MD, William R. Auger, MD, Thomas J. Waltman, MD, FACC, Michael Madani, MD, FACS, Ajit B. Raisinghani, MD, Anthony N. DeMaria, MD, MACC and Daniel G. Blanchard, MD, FACC^,_*

^_* Division of Cardiology, University of California Irvine School of Medicine, Irvine, California
Division of Cardiology, UCSD Medical Center and University of California, San Diego School of Medicine, San Diego, California
Division of Pulmonary Medicine, UCSD Medical Center and University of California, San Diego School of Medicine, San Diego, California
Division of Cardiothoracic Surgery, UCSD Medical Center and University of California, San Diego School of Medicine, San Diego, California.

Manuscript received March 21, 2006; revised manuscript received October 30, 2006, accepted October 31, 2006.

^_* Reprint requests and correspondence: Dr. Daniel G. Blanchard, UCSD Division of Cardiology, 9350 Campus Point Drive, #1D, La Jolla, California 92037. (Email: dblanchard{at}ucsd.edu).

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.

Abbreviations and Acronyms   CTEPH = chronic thromboembolic pulmonary hypertension   D = diastolic component of pulmonary venous flow velocity   Em = early diastolic mitral annular velocity   LV = left ventricle/ventricular   PAH = pulmonary arterial hypertension   PAP = pulmonary artery pressure   PCWP = pulmonary capillary wedge pressure   PTE = pulmonary thromboendarterectomy   RV = right ventricle/ventricular   S = systolic component of pulmonary venous flow velocity

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