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Pathophysiology of Impaired Right and Left Ventricular Function in Chronic Embolic Pulmonary Hypertension^*

Changes After Pulmonary Thromboendarterectomy

^* From the 2nd Medical Clinic, Department of Cardiology (Drs. Menzel, Wagner, Mohr-Kahaly, Braeuninger, and Meyer), and Clinic for Cardiothoracic and Vascular Surgery (Drs. Kramm and Mayer), Johannes Gutenberg University, Langenbeckstrasse 1, D-55101 Mainz, Germany.

Correspondence to: Thomas Menzel, MD, Richard Wagner Strasse 17A, D-65193 Wiesbaden, Germany; e-mail: menzel{at}mail.uni-mainz.de

Study objectives: This study sought to evaluate the pathophysiology of left and right heart failure in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who were hospitalized to undergo pulmonary thromboendarterectomy (PTE).

Design: Thirty-nine patients (16 women and 23 men; mean ± SD age, 55 ± 12 years) with severe CTEPH were examined before and 13 ± 8 days after PTE by way of transthoracic echocardiography and right heart catheterization.

Measurements and results: Examination results confirmed in all cases that before surgery the right ventricles were enlarged and systolic function was impaired. Moderate to severe tricuspid valve regurgitation was observed. Left ventricular eccentricity indexes reflected a leftward displacement of the interventricular septum. End-diastolic left ventricular size and systolic function had decreased, and the left ventricular filling pattern showed impaired diastolic function. After surgery, mean pulmonary artery pressure was significantly lower (48 ± 10 mm Hg vs 25 ± 7 mm Hg; p < 0.05). The calculated end-diastolic and end-systolic right ventricular areas had decreased: 30 ± 7 cm² vs 21 ± 5 cm² (p < 0.05) and 24 ± 6 cm² vs 14 ± 4 cm² (p < 0.05), respectively. Right ventricular fractional area change had increased (20 ± 7% vs 33 ± 8%; p < 0.05). Most of the patients exhibited a marked decrease in the severity of tricuspid regurgitation. Septal motion, left ventricular systolic function, and diastolic filling pattern returned to normal values (early to late diastolic left ventricular inflow ratio, 0.70 ± 0.33 vs 1.35 ± 0.51; p < 0.05). The mean cardiac index also improved (2.7 ± 0.6 L/min/m² vs 3.7 ± 0.8 L/min/m²).

Conclusions: In CTEPH, functions are impaired in the right as well as the left ventricles of the heart. Improved lung perfusion and the reduction of right ventricular pressure overload are direct results of PTE, which in turn bring a profound reduction of right ventricular size and a recovery of systolic function. Normalization of interventricular septal motion as well as improved venous return to the left atrium lead to a normalization of left ventricular diastolic and systolic function, and the cardiac index improves.

Key Words: chronic thromboembolic pulmonary hypertension • echocardiography • pulmonary thromboendarterectomy

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