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Adriano R. Tonelli, MD; Raed A. Dweik, MD, FCCP
Author and Funding Information

From the Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic.

Correspondence to: Raed A. Dweik, MD, FCCP, Pulmonary Vascular Program, 9500 Euclid Ave A-90, Cleveland, OH 44195; e-mail: dweikr@ccf.org.


Funding/Support: This study was funded by CTSA KL2 [Grant RR024990] (salary support to Dr Tonelli) from the National Center for Research Resources, a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Dr Dweik receives salary support from the NIH [Grants HL081064, HL107147, HL095181, and RR026231] and a Biomedical Research and Commercialization Program 08-049 Third Frontier Program grant from the Ohio Department of Development.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(1):273. doi:10.1378/chest.12-2145
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Published online
To the Editor:

We agree with the important remarks by Dr Claver and colleagues pertaining to our article in CHEST.1 There is a strong relationship between left atrial (LA) enlargement and the degree of left ventricular (LV) diastolic dysfunction.2 The increase in left atrial volume reflects the cumulative effects of elevated filling pressures over time. In patients with pulmonary arterial hypertension (PAH), a mitral filling pattern of impaired relaxation is commonly observed.1,3 However, this degree of diastolic dysfunction is not related to elevated left-sided filling pressures because they are normal or low.1,3 The abnormal mitral inflow pattern is likely explained by ventricular interdependence.1,3,4 Because the pericardium limits the space available for the ventricles to expand into, right ventricular pressure overload leads to leftward bowing of the interventricular septum, with a decrease in LV chamber size and filling.5 This reciprocal relation of the ventricles is also observed at the auricular level, given that there is also limited room for the right atrium (RA) to expand. This “atrial interdependence” leads to displacement of the interatrial septum and reduction of the volume of the left atrium.

In our study, the LA volume index was lower in patients with diastolic dysfunction grade ≥ I (18±8 mL/m2 vs 26±12 mL/m2, P = .03).1 This phenomenon was likely due to a compression of the left atrium by the right one, because these patients had higher RA pressure (12±6 mm Hg vs 6±3 mm Hg, P = .04) and larger RA to pulmonary artery occlusion gradient (2.3±6.6 mm Hg vs −6.7±3.7 mm Hg, P = .001). In support of our findings, Kasner et al4 recently described the presence of impaired LV diastolic function due to ventricular interaction in patients with mild idiopathic PAH. They compared patients with idiopathic PAH with subjects who had isolated LV diastolic dysfunction and found that LA volume was larger only in the latter group.

In our cohort, we did not take into account the atrial size to make decisions regarding diastolic dysfunction in these patients. Nevertheless, we found discrepancies between the initial read and the subsequent echocardiographic review in five out of 61 cases (8%). A third physician reviewed these cases and a consensus was achieved. Of these five cases, an initial grade I diastolic dysfunction was reclassified as normal, a grade II was changed to grade I, and no changes were made in the remaining three patients. In summary, although LA size determination is part of the grading scheme for diastolic dysfunction,3 this particular criterion should not be used in patients with PAH.

Acknowledgments

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

Tonelli AR, Plana JC, Heresi GA, Dweik RA. Prevalence and prognostic value of left ventricular diastolic dysfunction in idiopathic and heritable pulmonary arterial hypertension. Chest. 2012;141(6):1457-1465. [CrossRef] [PubMed]
 
Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial volume as a morphophysiologic expression of left ventricular diastolic dysfunction and relation to cardiovascular risk burden. Am J Cardiol. 2002;90(12):1284-1289. [CrossRef] [PubMed]
 
Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2009;22(2):107-133. [CrossRef] [PubMed]
 
Kasner M, Westermann D, Steendijk P, et al. Left ventricular dysfunction induced by nonsevere idiopathic pulmonary arterial hypertension: a pressure-volume relationship study. Am J Respir Crit Care Med. 2012;186(2):181-189. [CrossRef] [PubMed]
 
Gan CT, Lankhaar JW, Marcus JT, et al. Impaired left ventricular filling due to right-to-left ventricular interaction in patients with pulmonary arterial hypertension. Am J Physiol Heart Circ Physiol. 2006;290(4):H1528-H1533. [PubMed]
 

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References

Tonelli AR, Plana JC, Heresi GA, Dweik RA. Prevalence and prognostic value of left ventricular diastolic dysfunction in idiopathic and heritable pulmonary arterial hypertension. Chest. 2012;141(6):1457-1465. [CrossRef] [PubMed]
 
Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial volume as a morphophysiologic expression of left ventricular diastolic dysfunction and relation to cardiovascular risk burden. Am J Cardiol. 2002;90(12):1284-1289. [CrossRef] [PubMed]
 
Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2009;22(2):107-133. [CrossRef] [PubMed]
 
Kasner M, Westermann D, Steendijk P, et al. Left ventricular dysfunction induced by nonsevere idiopathic pulmonary arterial hypertension: a pressure-volume relationship study. Am J Respir Crit Care Med. 2012;186(2):181-189. [CrossRef] [PubMed]
 
Gan CT, Lankhaar JW, Marcus JT, et al. Impaired left ventricular filling due to right-to-left ventricular interaction in patients with pulmonary arterial hypertension. Am J Physiol Heart Circ Physiol. 2006;290(4):H1528-H1533. [PubMed]
 
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