The Relationship Between the Right Ventricle and its Load in Pulmonary Hypertension

• Published in: Journal of the American College of Cardiology Vol. 69; no. 2; pp. 236 - 243
• Main Authors: Vonk Noordegraaf, Anton, MD, PhD, Westerhof, Berend E., PhD, Westerhof, Nico, PhD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 17.01.2017; Elsevier Limited
• Subjects: Cardiac Volume - physiology; Cardiology; Cardiomyocytes; Cardiovascular; Compliance; compliance-resistance relation; Follow-Up Studies; Heart failure; Heart Ventricles - physiopathology; Humans; Hypertension, Pulmonary - physiopathology; Hypertrophy, Right Ventricular - physiopathology; Internal Medicine; Magnetic Resonance Imaging - methods; Myocardial Contraction - physiology; pulmonary arterial system; Pulmonary arteries; Pulmonary Artery - physiopathology; Pulmonary Circulation - physiology; Pulmonary hypertension; right heart failure; Risk Factors; Stroke Volume - physiology; Veins & arteries; ventriculoarterial coupling; compliance-resistance relation; mPAP; PP; RVEF; mean pulmonary artery pressure; RV; E ed; pulmonary arterial wedge pressure; arterial time constant PVR · TAC; pulmonary hypertension; E a; single-beat method-predicted isovolumic systolic pressure; LV; ventriculoarterial coupling; PVR; pulmonary arterial system; pressure–volume; RVESV; cardiac output; right ventricle/ventricular; total arterial compliance; P-V; right ventricular end-systolic volume; left ventricle/ventricular; pulmonary artery pressure; pulmonary arterial hypertension; pulse pressure; SV; P isovol; end-diastolic elastance; CMR; right heart failure; CO; PAWP; stroke volume; chronic thromboembolic pulmonary hypertension; RC; right ventricular ejection fraction; arterial elastance; E es; PAH; TAC; end-systolic elastance; PH; CTEPH; pulmonary vascular resistance; cardiac magnetic resonance; PAP; Pisovol; Eed; Ees; Ea
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2016.10.047

Abstract In pulmonary hypertension, the right ventricle adapts to the increasing vascular load by enhancing contractility (“coupling”) to maintain flow. Ventriculoarterial coupling implies that stroke volume changes little while preserving ventricular efficiency. Ultimately, a phase develops where ventricular dilation occurs in an attempt to limit the reduction in stroke volume, with uncoupling and increased wall stress as a consequence. With pressure–volume analysis, we separately describe the changing properties of the pulmonary vascular system and the right ventricle, as well as their coupling, as important concepts for understanding the changes that occur in pulmonary hypertension. On the basis of the unique properties of the pulmonary circulation, we show how all relevant physiological parameters can be derived using an integrative approach. Because coupling is maintained by hypertrophy until the end stage of the disease, when progressive dilation begins, right ventricular volume is the essential parameter to measure in follow-up of patients with pulmonary hypertension.