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Ventriculo ‐ arterial coupling detects occult RV dysfunction in chronic thromboembolic pulmonary vascular disease

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ABSTRACT

Chronic thromboembolic disease (CTED) is suboptimally defined by a mean pulmonary artery pressure (mPAP) <25 mmHg at rest in patients that remain symptomatic from chronic pulmonary artery thrombi. To improve identification of right ventricular (RV) pathology in patients with thromboembolic obstruction, we hypothesized that the RV ventriculo‐arterial (Ees/Ea) coupling ratio at maximal stroke work (Ees/Eamax sw) derived from an animal model of pulmonary obstruction may be used to identify occult RV dysfunction (low Ees/Ea) or residual RV energetic reserve (high Ees/Ea). Eighteen open chested pigs had conductance catheter RV pressure‐volume (PV)‐loops recorded during PA snare to determine Ees/Eamax sw. This was then applied to 10 patients with chronic thromboembolic pulmonary hypertension (CTEPH) and ten patients with CTED, also assessed by RV conductance catheter and cardiopulmonary exercise testing. All patients were then restratified by Ees/Ea. The animal model determined an Ees/Eamax sw = 0.68 ± 0.23 threshold, either side of which cardiac output and RV stroke work fell. Two patients with CTED were identified with an Ees/Ea well below 0.68 suggesting occult RV dysfunction whilst three patients with CTEPH demonstrated Ees/Ea ≥ 0.68 suggesting residual RV energetic reserve. Ees/Ea > 0.68 and Ees/Ea < 0.68 subgroups demonstrated constant RV stroke work but lower stroke volume (87.7 ± 22.1 vs. 60.1 ± 16.3 mL respectively, P = 0.006) and higher end‐systolic pressure (36.7 ± 11.6 vs. 68.1 ± 16.7 mmHg respectively, P < 0.001). Lower Ees/Ea in CTED also correlated with reduced exercise ventilatory efficiency. Low Ees/Ea aligns with features of RV maladaptation in CTED both at rest and on exercise. Characterization of Ees/Ea in CTED may allow for better identification of occult RV dysfunction.

No MeSH data available.


Related in: MedlinePlus

The individual data points for the patients with CTED (n = 10) or CTEPH (n = 10) overlaid on top of the mean regression lines determined from the animal model for the relation between afterload quantified by Ea and (A) SW; (B) SW/PVA; and (C) CO. The individual data points for the patients with CTED (n = 10) or CTEPH (n = 10) overlaid on top of the mean regression lines determined from the animal model for the relation between ventriculo‐arterial coupling ratio (Ees/Ea) and (D) SW; (E) SW/PVA; and (F) CO.
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phy213227-fig-0004: The individual data points for the patients with CTED (n = 10) or CTEPH (n = 10) overlaid on top of the mean regression lines determined from the animal model for the relation between afterload quantified by Ea and (A) SW; (B) SW/PVA; and (C) CO. The individual data points for the patients with CTED (n = 10) or CTEPH (n = 10) overlaid on top of the mean regression lines determined from the animal model for the relation between ventriculo‐arterial coupling ratio (Ees/Ea) and (D) SW; (E) SW/PVA; and (F) CO.

Mentions: Two patients with CTED were identified with an Ees/Ea < 0.68 indicating occult RV pathology (Fig. 4) and three CTEPH patients still had residual RV energetic reserve (Ees/Ea ≥ 0.68). This equated to a reclassification of 25% of the entire cohort. The Ees/Ea coupling ratio for these three misclassified CTED patients was 0.35 and 0.45, even though they presented with normal mPAP (15 and 19 mmHg) and PVR (157 and 230 dyne/sec/cm5).


Ventriculo ‐ arterial coupling detects occult RV dysfunction in chronic thromboembolic pulmonary vascular disease
The individual data points for the patients with CTED (n = 10) or CTEPH (n = 10) overlaid on top of the mean regression lines determined from the animal model for the relation between afterload quantified by Ea and (A) SW; (B) SW/PVA; and (C) CO. The individual data points for the patients with CTED (n = 10) or CTEPH (n = 10) overlaid on top of the mean regression lines determined from the animal model for the relation between ventriculo‐arterial coupling ratio (Ees/Ea) and (D) SW; (E) SW/PVA; and (F) CO.
© Copyright Policy - creativeCommonsBy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5392517&req=5

phy213227-fig-0004: The individual data points for the patients with CTED (n = 10) or CTEPH (n = 10) overlaid on top of the mean regression lines determined from the animal model for the relation between afterload quantified by Ea and (A) SW; (B) SW/PVA; and (C) CO. The individual data points for the patients with CTED (n = 10) or CTEPH (n = 10) overlaid on top of the mean regression lines determined from the animal model for the relation between ventriculo‐arterial coupling ratio (Ees/Ea) and (D) SW; (E) SW/PVA; and (F) CO.
Mentions: Two patients with CTED were identified with an Ees/Ea < 0.68 indicating occult RV pathology (Fig. 4) and three CTEPH patients still had residual RV energetic reserve (Ees/Ea ≥ 0.68). This equated to a reclassification of 25% of the entire cohort. The Ees/Ea coupling ratio for these three misclassified CTED patients was 0.35 and 0.45, even though they presented with normal mPAP (15 and 19 mmHg) and PVR (157 and 230 dyne/sec/cm5).

View Article: PubMed Central - PubMed

ABSTRACT

Chronic thromboembolic disease (CTED) is suboptimally defined by a mean pulmonary artery pressure (mPAP) &lt;25&nbsp;mmHg at rest in patients that remain symptomatic from chronic pulmonary artery thrombi. To improve identification of right ventricular (RV) pathology in patients with thromboembolic obstruction, we hypothesized that the RV ventriculo&#8208;arterial (Ees/Ea) coupling ratio at maximal stroke work (Ees/Eamax sw) derived from an animal model of pulmonary obstruction may be used to identify occult RV dysfunction (low Ees/Ea) or residual RV energetic reserve (high Ees/Ea). Eighteen open chested pigs had conductance catheter RV pressure&#8208;volume (PV)&#8208;loops recorded during PA snare to determine Ees/Eamax sw. This was then applied to 10 patients with chronic thromboembolic pulmonary hypertension (CTEPH) and ten patients with CTED, also assessed by RV conductance catheter and cardiopulmonary exercise testing. All patients were then restratified by Ees/Ea. The animal model determined an Ees/Eamax sw&nbsp;=&nbsp;0.68&nbsp;&plusmn;&nbsp;0.23 threshold, either side of which cardiac output and RV stroke work fell. Two patients with CTED were identified with an Ees/Ea well below 0.68 suggesting occult RV dysfunction whilst three patients with CTEPH demonstrated Ees/Ea&nbsp;&ge;&nbsp;0.68 suggesting residual RV energetic reserve. Ees/Ea&nbsp;&gt;&nbsp;0.68 and Ees/Ea&nbsp;&lt;&nbsp;0.68 subgroups demonstrated constant RV stroke work but lower stroke volume (87.7&nbsp;&plusmn;&nbsp;22.1 vs. 60.1&nbsp;&plusmn;&nbsp;16.3&nbsp;mL respectively, P&nbsp;=&nbsp;0.006) and higher end&#8208;systolic pressure (36.7&nbsp;&plusmn;&nbsp;11.6 vs. 68.1&nbsp;&plusmn;&nbsp;16.7&nbsp;mmHg respectively, P&nbsp;&lt;&nbsp;0.001). Lower Ees/Ea in CTED also correlated with reduced exercise ventilatory efficiency. Low Ees/Ea aligns with features of RV maladaptation in CTED both at rest and on exercise. Characterization of Ees/Ea in CTED may allow for better identification of occult RV dysfunction.

No MeSH data available.


Related in: MedlinePlus