Abstract
Background: The normal and dilated heart behaves as a single functional unit during preload reduction; volume unloading in the setting of diastolic ventricular interaction allows for increased left ventricular (LV) filling.
Hypothesis: We hypothesized that reduction of venous return induced by a physiologic stimulus (tilting) or by acute angiotensin‐converting enzyme (ACE) inhibitors in dilated heart is likely to have a marked and similar effect on ventricular chamber geometry and filling. This study was designed to assess how the normal and dilated heart adapts to preload reduction.
Methods: Twenty normal subjects and 20 patients with moderate heart failure due to dilated cardiomyopathy were studied with two‐dimensional and Doppler echocardiography in supine position (B) and after 40° of head‐up tilting (T). The following day, patients repeated supine (C) and tilting test (TC) after administration of captopril (25 mgs.1.). Right ventricular (RV) and LV dimensions, LV geometry, and tricuspid, mitral, and pulmonary venous flow patterns were recorded at each step of the study.
Results: In the two groups, T was associated with reduction of RV area and LV volumes; C and TC produced a similar effect on RV and LV. Changes in LV septal‐lateral diameter and anterior‐posterior diameter were different at each step of the study: during T (both groups) and after C and TC, the septallateral diameter increased slightly while the anterior‐posterior diameter decreased. During T, mitral and tricuspid peak flow velocities decreased, peak late velocities were unchanged, and the deceleration time of mitral flow increased; the systolic forward flow of pulmonary venous flow decreased, the diastolic forward flow did not change, and the difference in duration between reverse pulmonary flow and mitral peak late flow decreased; C and CT induced similar changes.
Conclusion: Preload reduction induced by tilting or by ACE inhibitors induces profound and similar effects on LV and RV dimensions, LV geometry, and biventricular filling. Reduction of RV dimension is associated with adaptation of LV geometry and decrease of LV diastolic pressure, which facilitates LV filling and pulmonary venous drainage; ACE inhibition associated with tilting exerts an additional effect on these changes. These data confirm the role of ventricular interaction in modulating LV filling in heart failure.
Keywords: ventricular interdependence, dilated cardiomyopathy, angiotensin‐converting enzyme inhibition, Doppler echocardiography
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References
- 1. Janicki J: Influence of the pericardium and ventricular interdependence of left ventricular diastolic and systolic function in patients with heart failure. Circulation 1990; (suppl III): III‐15–III‐20 [PubMed]
- 2. Gilbert J, Glantz A: Determinants of left ventricular filling and of the diastolic pressure‐volume relation. Circulation 1989; 64: 827–852 [DOI] [PubMed] [Google Scholar]
- 3. Bove A, Santamore W: Ventricular interdependence. Prog Cardiovasc Dis 1981; 23: 365–387 [DOI] [PubMed] [Google Scholar]
- 4. Louie E, Lin S, Reynertson S, Brundage B, Levitsky, Rich S: Pressure and volume loading of the right ventricle have opposite effects on left ventricular ejection fraction. Circulation 1995; 92: 819–824 [DOI] [PubMed] [Google Scholar]
- 5. Atherton J, Moore T, Lele S, Thomson H, Galbrait A, Belenkie I, Tyberg J, Frenneaux M: Diastolic ventricular interaction in chronic heart failure. Lancet 1997; 349: 1720–1724 [DOI] [PubMed] [Google Scholar]
- 6. Pepi M, Guazzi M, Maltagliati A, Berna G, Tamborini G: Diastolic ventricular interaction in normal and dilated heart during head‐up tilting. Clin Cardiol 2000; 23: 665–672 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Takahashi T, Iizuka M, Sato H, Serizawa T, Momomura S, Mochizuki T, Kohmoto O, Aoyagi T, Matsui H, Ikenouchi H, Sakamoto T, Sugimoto T: Doppler echocardiographic‐determined changes in left ventricular diastolic filling flow velocity during the lower body positive and negative pressure method. Am J Cardiol 1990; 65: 237–241 [DOI] [PubMed] [Google Scholar]
- 8. Triulzi M, Castini D, Ornaghi M, Vitolo E: Effects of preload reduction on mitral flow velocity pattern in normal subjects. Am J Cardiol 1990; 66: 995–1001 [DOI] [PubMed] [Google Scholar]
- 9. Courtois M, Vered Z, Barzilai B, Ricciotti N, Perez J, Ludbrook P: The transmitral pressure‐flow velocity relation. Effect of abrupt preload reduction. Circulation 1988; 78: 1459–1468 [DOI] [PubMed] [Google Scholar]
- 10. Choong C, Herrman H, Weiman A, Fifer M: Preload dependence of Doppler‐derived indexes of left ventricular diastolic function in humans. J Am Coll Cardiol 1987; 10: 800–808 [DOI] [PubMed] [Google Scholar]
- 11. Thomas J, Choong C, Flachskampf F, Weyman A: Analysis of the early transmitral Doppler velocity curve: Effect of primary physiologic changes and compensatory preload adjustment. J Am Coll Cardiol 1990; 16: 644–655 [DOI] [PubMed] [Google Scholar]
- 12. Lee J, Tajimi T, Patritti J, Ross J: Preload reserve and mechanisms of after‐load mismatch in normal conscious dog. Am J Physiol 1986; 250: H464–H473 [DOI] [PubMed] [Google Scholar]
- 13. Kiyoshige K, Oki T, Fukuda N, Iuchi A, Tabata T, Fujimoto T, Manabe K, Kageji Y, Sasaki M, Ito S: Changes in left ventricular inflow and pulmonary venous flow velocities during preload alteration in dilated heart. Clin Cardiol 1996; 19: 38–44 [DOI] [PubMed] [Google Scholar]
- 14. Guazzi M, Pepi M, Maltagliati A, Celeste F, Muratori M, Tamborini G: How the two sides of the heart adapt to graded impedance to venous return with head‐up titlting. J Am Coll Cardiol 1995; 26; 1732–1740 [DOI] [PubMed] [Google Scholar]
- 15. Thomas J, Weyman A: Echocardiographic Doppler evaluation of left ventricular diastolic function. Physics and physiology. Circulation 1991; 84: 977–990 [DOI] [PubMed] [Google Scholar]
- 16. Guazzi M, Maltagliati A, Tamborini G, Celeste F, Pepi M, Muratori M, Berti M, Guazzi MD: How the left and right sides of the heart, as well as pulmonary venous drainage, adapt to an increasing degree of head‐up tilting in hypertrophic cardiomyopathy: Differences from the normal heart. J Am Coll Cardiol 2000; 36: 185–193 [DOI] [PubMed] [Google Scholar]
- 17. Schiller N, Shah P, Crawford M, DeMaria A, Devereux R, Feigenbaum H, Gutfesels H, Reichek N, Sahn D, Schnittger I, Silverman N, Tajik A: Recommendations for quantitation of the left ventricle by two‐dimensional echocardiography. J Am Soc Echocardiogr 1989; 2: 358–367 [DOI] [PubMed] [Google Scholar]
- 18. Roosvoll O, Hatle L: Pulmonary venous flow velocities recorded by trans‐thoracic Doppler ultrasound: Relation to left ventricular diastolic pressures. J Am Coll Cardiol 1993; 21: 1687–1696 [DOI] [PubMed] [Google Scholar]
- 19. Miyatake K, Izumi S, Okamoto M, Kinoshita N, Asonuma H, Nakagawa H, Yamamoto K, Takamiya M, Sakakibara H, Nimura Y: Semiquantitative grading of severity of mitral regurgitation by real‐time two‐dimensional Doppler flow imaging technique. J Am Coll Cardiol 1986; 7: 82–88 [DOI] [PubMed] [Google Scholar]
- 20. Nishimura R, Tajik J: Evaluation of diastolic filling of left ventricle in health and disease: Doppler echocardiography is the clinician's Rosetta stone. J Am Coll Cardiol 1997; 30: 8–18 [DOI] [PubMed] [Google Scholar]
- 21. Yamamoto K, Nishimura R, Chaliki H, Appleton C, Holmes D, Redfield M: Determination of left ventricular filling pressure by Doppler echocardiography in patients with coronary artery disease: Critical role of left ventricular systolic function. J Am Coll Cardiol 1997; 30: 1819–1826 [DOI] [PubMed] [Google Scholar]
- 22. Pepi M, Sganzerla P, Barbier P, Moruzzi P: Volume and pressure dependence of left and right ventricular filling in dilated cardiomyopathy. Am J Noninvas Cardiol 1993; 7: 106–112 [Google Scholar]
- 23. Pepi M, Marenzi GC, Agostoni PG, Doria E, Barbier P, Muratori M, Celeste F, Guazzi MD: Sustained cardiac diastolic changes elicited by ultrafiltration in patients with moderate congestive heart failure: Pathophysiological correlates. Br Heart J 1993; 70: 135–140 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Atherton J, Moore T, Thomson H, Frenneaux M: Restrictive left ventricular filling patterns are predictive of diastolic ventricular interaction in chronic heart failure. J Am Coll Cardiol 1998; 31: 413–418 [DOI] [PubMed] [Google Scholar]
- 25. Turini GA, Brunner HR, Ferguson RR, Rivier RK, Gavras H: Congestive heart failure in normotensive man. Hemodynamics, renin, and angiotensin‐II blockade. Br Heart J 1978; 40: 1134–1142 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Gavras H, Faxon DP, Berkoben J, Brunner J, Ryan TJ: Angiotensin‐converting enzyme inhibition in patients with congestive heart failure. Circulation 1978; 58: 770–776 [DOI] [PubMed] [Google Scholar]
- 27. Konstam M, Kronemberg M, Udelson J, Metheral J, Dolan N, Edens T, Howe D, Yusuf S, Youngblood M, Toltsis H, and the SOLVD Investigators : Effect of acute converting enzyme inhibition on left ventricular filling in patients with congestive heart failure. Relation to right ventricular volumes. Circulation 1990; 81 (suppl III) III–115–III–122 [PubMed] [Google Scholar]
- 28. Henein M, O'Sullivan C, Coats A, Gibson D: Angiotensin‐converting enzyme inhibitors revert abnormal right ventricular filling in patients with restrictive left ventricular disease. J Am Coll Cardiol 1998; 32: 1187–1193 [DOI] [PubMed] [Google Scholar]
- 29. Smiseth O, Manyari D, Lima J, Scott‐Douglas N, Kingma I, Smith E, Tyberg J: Modulation of vascular capacitance by angiotensin and nitroprusside: A mechanism of changes in pericardial pressure. Circulation 1987; 76: 875–883 [DOI] [PubMed] [Google Scholar]
- 30. Pinamonti B, Di Lenarda A, Sinagra G, Camerini F: Restrictive left ventricular filling pattern in dilated cardiomyopathy assessed by Doppler echocardiography: Clinical, echocardiographic and hemodynamic correlations and prognostic implications. J Am Coll Cardiol 1993; 22: 808–815 [DOI] [PubMed] [Google Scholar]
- 31. Rihal C, Nishimura R, Hatler L, Bailey K, Tajik J: Systolic and diastolic dysfunction in patients with clinical diagnosis of dilated cardiomyopathy. Relation to symptoms and prognosis. Circulation 1994; 90: 2772–2779 [DOI] [PubMed] [Google Scholar]
- 32. Pepi M, Agostoni PG, Marenzi GC, Doria E, Guazzi M, Lauri GF, Maltagliati A, Guazzi MD: The influence of diastolic and systolic function on exercise performance in heart failure due to dilated cardiomyopathy or is‐chemic heart disease. Eur J Heart Failure 1999; 1: 161–167 [DOI] [PubMed] [Google Scholar]
- 33. SOLVD Investigators : Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293–302 [DOI] [PubMed] [Google Scholar]
- 34. Pozzoli M, Traversi E, Cioffi G, Stenner R, Sanarico M, Tavazzi L: Loading manipulation improve the prognostic value of Doppler evaluation of mitral flow in patients with chronic heart failure. Circulation 1997; 95: 1222–1230 [DOI] [PubMed] [Google Scholar]
- 35. Temporelli P, Corrà U, Imparato A, Bosimini E, Scapellato F, Giannuzzi P: Reversible restrictive left ventricular diastolic filling with optimized oral therapy predicts a more favorable prognosis in patients with chronic heart failure. J Am Coll Cardiol 1998; 31: 1591–1597 [DOI] [PubMed] [Google Scholar]
- 36. Sander G, McKinnie J, Greenberg S, Giles T: Angiotensin‐converting enzyme inhibitors and angiotensin II receptor antagonists in the treatment of heart failure caused by left ventricular systolic dysfunction. Progr Cardiovasc Dis 1999; 41: 265–300 [DOI] [PubMed] [Google Scholar]
- 37. Appleton C, Galloway J, Gonzalez M, Gaballa M, Basnight M: Estimation of left ventricular filling pressure using two‐dimensional and Doppler echocardiography in adult patients with cardiac diseases. Additional value of analyzing left atrial size, left atrial ejection fraction and the difference in duration of pulmonary venous and mitral flow velocity at atrial contraction. J Am Coll Cardiol 1993; 22: 1972–1982 [DOI] [PubMed] [Google Scholar]