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Original Articles

Right-to-Left Ventricular Diastolic Delay in Chronic Thromboembolic Pulmonary Hypertension Is Associated With Activation Delay and Action Potential Prolongation in Right Ventricle

Maxim Hardziyenka, MD; Maria E. Campian, MD; Berto J. Bouma, MD, PhD; André C. Linnenbank, PhD; H.A.C.M. Rianne de Bruin-Bon, BSc; Jaap J. Kloek, MD; Allard C. van der Wal, MD, PhD; Jan Baan, Jr, MD, PhD; Edouard M. de Beaumont, MD; Herre J. Reesink, MD, PhD; Jacques M.T. de Bakker, PhD; Paul Bresser, MD, PhD and Hanno L. Tan, MD, PhD

From the Heart Failure Research Center (M.H., M.E.C., A.C.L., J.M.T.B., H.L.T.), Academic Medical Center, University of Amsterdam, The Netherlands; Interuniversity Cardiology Institute of The Netherlands (M.H., J.M.T.B.), Utrecht, The Netherlands; the Departments of Cardiology (B.J.B., H.A.C.M.R.d.B.-B., J.B.), Cardiothoracic Surgery (J.J.K.), Pathology (A.C.v.d.W.), Anesthesiology (E.M.d.B.), and Pulmonology (H.J.R., P.B.), Academic Medical Center, University of Amsterdam, The Netherlands.

Correspondence to Hanno L. Tan, MD, PhD, Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail h.l.tan{at}amc.nl

Received February 6, 2009; accepted July 23, 2009.

Background— Delayed left ventricle (LV)–to–right ventricle (RV) peak shortening results in cardiac output reduction in patients with chronic thromboembolic hypertension (CTEPH) and other types of pulmonary arterial hypertension. Why the synchrony between LV and RV is lost is unknown. We hypothesized that RV electrophysiological remodeling, notably, conduction slowing and action potential prolongation, contribute to this loss in synchrony.

Methods and Results— We conducted epicardial mapping during pulmonary endarterectomy in 26 patients with CTEPH and compared these findings with clinical, hemodynamic, and echocardiographic variables. We consecutively placed a multielectrode grid on the epicardium of the RV free wall and LV lateral wall. These regions corresponded to RV and LV areas where echocardiographic Doppler sample volumes were placed to measure RV-to-LV diastolic interventricular delay. RV and LV epicardial action potential duration was assessed by measuring activation-recovery interval. Onset of diastolic relaxation of RV free wall with respect to LV lateral wall (diastolic interventricular delay) was delayed by 38±31 ms in patients with CTEPH versus –12±13 ms in control subjects (P<0.001), because, in patients with CTEPH, RV completed electric activation later than LV (65±20 versus 44±7 ms, P<0.001) and epicardial action potential duration, as assessed by activation-recovery interval measurement, was longer in RV free wall than in LV lateral wall (253±29 versus 240±22 ms, P<0.001).

Conclusion— Additive effects of electrophysiological changes in RV, notably, conduction slowing and action potential prolongation, assessed by epicardial activation-recovery interval, contribute to diastolic interventricular delay in patients with CTEPH.

Key Words: chronic thromboembolic pulmonary hypertension • echocardiography • electrophysiological remodeling • diastolic interventricular dyssynchrony

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CLINICAL PERSPECTIVE

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