Right ventricular adaptation to pulmonary pressure load in patients with chronic thromboembolic pulmonary hypertension before and after successful pulmonary endarterectomy - a cardiovascular magnetic resonance study

BACKGROUND: The aim of the study was to characterize RV adaptation to varying loading conditions in patients with chronic thromboembolic hypertension (CTEPH) before and after pulmonary endarterectomy (PEA). Nearly 4% of patients with pulmonary embolism develop CTEPH. PEA offers a cure with excellent outcome. By use of cardiovascular magnetic resonance (CMR) combined with hemodynamic measurements pulmonary arterial elastance (E(a-pulm_i)), end-systolic right ventricular elastance (E(es-RV_i)) and ventriculo-arterial coupling (E(a-pulm_i)/E(es-RV_i)) can be studied before and after PEA. METHODS: Sixty-five patients (mean age 41 ± 12 years, 28 female) underwent CMR pre- and post-PEA. Ejection fraction (EF), end-diastolic (EDV(i)), end-systolic (ESV(i)), and stroke (SV(i)) volumes were indexed for body surface area. E(a-pulm_i) was calculated as pulmonary artery mean pressure (mPAP)/SV(i), and E(es-RV_i) as mPAP/ESV(i). RESULTS: mPAP decreased from 47 ± 12 to 25 ± 9 mmHg, p =0.0001. E(a-pulm_i) was increased before PEA and normalized afterwards (2.8 ± 2.1 vs. 0.85 ± 0.4 mmHg/ml/m(2), p =0.0001). E(es-RV_i) was depressed before and after PEA (0.72 ± 0.27 vs. 0.66 ± 0.3 mmHg/ml/m(2), p =0.13). EF improved from 25 ± 12% to 46 ± 10%, p =0.0001, because ventriculo-arterial coupling was restored (4.2 ± 3 vs. 1.4 ± 0.6, p =0.0001). EDV(i) and ESVi mproved significantly (EDV(i) 92 ± 32 to 72 ± 23 ml, p =0.0001; ESV(i) 69 ± 31 to 41 ± 18 ml, p =0.0001). CONCLUSION: RV function is largely determined by afterload and returns to normal once afterload is normalized. This is paralleled by a significant improvement of CMR indices of right ventricular remodelling.