Affiliations: Wayne State University, Detroit, MI,
Mayo Clinic College of Medicine, Rochester, MN
Correspondence to: Hari Kumar Dandapantula, MD, Wayne State University, 550 E Canfield, Detroit, MI 48201; e-mail: email@example.com
We read the article “Unexplained Pulmonary Hypertension in Elderly Patients” by Shapiro et al in a recent issue of CHEST (January 2007)1 with a lot of interest. The study was well conducted; however, we have the following comments and would appreciate authors’ input on the following points:
1. It was pointed out that many elderly patients with unexplained pulmonary hypertension have pulmonary hypertension secondary to “diastolic dysfunction.” The term diastolic dysfunction was used on many occasions in the article. We want to bring to your attention that, based on the available evidence, the terminology is rapidly changing from diastolic heart failure to heart failure with normal ejection fraction.2It has clearly been shown in multiple clinical studies3 that left ventricular systolic function in the long axis is impaired in patients with so-called diastolic heart failure.
2. It was also suggested in the article (in the last paragraph on page 99) that only systolic heart failure responds to treatment with diuretics, while there is evidence that even heart failure with a normal ejection fraction is responsive to diuretic therapy.4
3. While explaining the concept of ventricular interdependence, Shapiro et al1 quoted a study by Little et al5 on the effect of right ventricular pressure on end-diastolic left ventricular pressure-volume in dogs without a pericardium, while all the patients described in their study had intact pericardia.
4. Historically, Bernheim is given the credit for hypothesizing the concept of ventricular interdependence.6In this particular context, an explanation based on a description of the “Bernheim effect” (ie, right ventricular failure associated with pulmonary hypertension secondary to left ventricular systolic/diastolic failure with a shift of the interventricular septum rightward) and the “reverse Bernheim effect” (ie, left ventricular systolic/diastolic dysfunction associated with a shift of the interventricular septum to the leftward secondary to right ventricular volume and pressure overload) would have enhanced the discussion.8
The authors have no conflicts of interest to disclose.
We are grateful for the careful review by Dr. Dandapantula et al. We offer the following comments:
1. We agree there is controversy regarding terminology in regards to diastolic heart failure vs heart failure with normal ejection fraction.1–3 We also agree that abnormalities in Doppler indexes of longitudinal systolic deformation in patients with heart failure and normal ejection fraction are interesting and that their significance remains to be defined,4as other studies5–6 have described an increase or at least no decrease in left ventricular end-systolic elastance (a load-independent method to characterize contractile performance) in patients with heart failure and normal ejection fraction.
2. We did not mean to imply that diuretics are not of use in diastolic heart failure. We apologize for any confusion generated.
3. While ventricular interdependence may be more potent with the pericardium intact, effects persist when it has been removed.7 In younger subjects with chronic idiopathic pulmonary artery hypertension, right ventricular pressure overload induces marked geometric changes and abnormal left ventricular relaxation, but rarely leads to elevated pulmonary capillary wedge pressure as highlighted in our article. Indeed, pulmonary capillary wedge pressure correlated strongly with age (r = 0.3, p < 0.0001) but not with pulmonary pressure. As acknowledged in our article, our data cannot definitively establish whether the observed elevation in left ventricular filling pressures is due to ventricular interdependence or intrinsic diastolic dysfunction. We conclude that further studies are needed to assist in this distinction in the increasing number of elderly patients evaluated for dyspnea and pulmonary hypertension.
4. We choose to use the term ventricular interdependence rather than the Bernheim effect but appreciate the historical clarification.
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