Contribution of External Forces to Left Ventricular Diastolic Pressure: Implications for the Clinical Use of the Starling Law

Dauterman, Kent W.; Pak, Peter H.; Maughan, W L; Nussbacher, Amit; Ariê, S; Liu, Chun–Peng; Kass, David A.

doi:10.7326/0003-4819-122-10-199505150-00001

Cited by 122 publications

(50 citation statements)

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“…25 In patients with CHF, marked external constraint to LV filling was present in the majority of patients with LVEDP/pulmonary capillary wedge pressure Ͼ15 mm Hg. 14,26 In accordance with our hypothesis, LV pacing significantly reduced this external constraint, presumably by causing a phase shift in LV filling relative to RV filling, as recently demonstrated in the LV pacing canine model, 17 in which LV relaxation and filling occurred relatively early compared with RV relaxation and filling. If so, RV diastolic pressure and pericardial pressure are likely to be lower at any given LV diastolic volume.…”

Section: Bleasdale Et Al LV Pacing Reduces Ventricular Interactionsupporting

confidence: 72%

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Left Ventricular Pacing Minimizes Diastolic Ventricular Interaction, Allowing Improved Preload-Dependent Systolic Performance

et al. 2004

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Background-Left ventricular (LV) pacing improves hemodynamics in patients with heart failure. We hypothesized that at least part of this benefit occurs by minimization of external constraint to LV filling from ventricular interaction. Methods and Results-We present median values (interquartile ranges) for 13 heart failure patients with LV pacing systems implanted for New York Heart Association class III/IV limitation. We used the conductance catheter method to measure LV pressure and volume simultaneously. External constraint was measured from the end-diastolic pressure-volume relation recorded during inferior vena caval occlusion, during LV pacing, and while pacing was suspended. External constraint to LV filling was reduced by 3.0 (4.6 to 0.6) mm Hg from 4.8 (0.6 to 7.5) mm Hg (PϽ0.01) in response to LV pacing; effective filling pressure (LV end-diastolic pressure minus external constraint) increased by 4.0 (2.2 to 5.8) mm Hg from 17.7 (13.3 to 22.6; PϽ0.01). LV end-diastolic volume increased by 10 (3 to 11) mL from 238 (169 to 295) mL (Pϭ0.01), whereas LV end-systolic volume did not change significantly (Ϫ1 [Ϫ2 to 3] mL from 180 [124 to 236] mL, Pϭ0.97), which resulted in an increase in stroke volume of 11 (5 to 13) mL from 49 (38 to 59) mL (PϽ0.01). LV stroke work increased by 720 (550 to 1180) mL ⅐ mm Hg from 3400 (2110 to 4480) mL ⅐ mm Hg (Pϭ0.01), and maximum dP/dt increased by 120 (2 to 161) mm Hg/s from 635 (521 to 767) mm Hg/s (Pϭ0.03). Conclusions-This study suggests a potentially important mechanism by which LV pacing may produce hemodynamic benefit. LV pacing minimizes external constraint to LV filling, resulting in an increase in effective filling pressure; the consequent increase in LV end-diastolic volume increases stroke volume via the Starling mechanism. (Circulation.

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Section: Bleasdale Et Al LV Pacing Reduces Ventricular Interactionsupporting

confidence: 72%

“…26 This acute reduction in RV volume removes external constraint to LV filling from the RV and pericardium. During this intervention, LVEDP was progressively reduced over several beats.…”

Section: Bleasdale Et Al LV Pacing Reduces Ventricular Interactionmentioning

confidence: 99%

Left Ventricular Pacing Minimizes Diastolic Ventricular Interaction, Allowing Improved Preload-Dependent Systolic Performance

et al. 2004

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“…These effects are further amplified during exercise where increased preload, further elevations in filling pressures and impaired reduction of afterload (due to a blunted vasodilator response to exercise) collectively contribute to exercise intolerance [44,45,47]. Exercise-induced elevation of pulmonary artery pressure and the ensuing elevation of right-sided pressures may contribute to poor functional capacity secondary to ventricular interdependence and increased pericardial constraint [43,89,90]. Lam et al [91] have recently shown that pulmonary hypertension may be present in up to 83% of HFpEF patients and found strong association between the severity of pulmonary hypertension and mortality.…”

Section: Venrticular-arterial Coupling and Endothelial Dysfunctionmentioning

confidence: 99%

Heart Failure with Preserved Ejection Fraction

Čulić

2017

N Engl J Med

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Heart failure with preserved ejection fraction (HFpEF) has recently emerged as a major cause of cardiovascular morbidity and mortality. Contrary to initial beliefs, HFpEF is now known to be as common as heart failure with reduced ejection fraction (HFrEF) and carries an unacceptably high mortality rate. With a prevalence that has been steadily rising over the past two decades, it is very likely that HFpEF will represent the dominant heart failure phenotype over the coming few years. The scarcity of trials in this semi-discrete form of heart failure and lack of unified enrolment criteria in the studies conducted to date might have contributed to the current absence of specific therapies. Understanding the epidemiological, pathophysiological and molecular differences (and similarities) between these two forms of heart failure is cornerstone to the development of targeted therapies. Carefully designed studies that adhere to unified diagnostic criteria with the recruitment of appropriate controls and adoption of practical end-points are urgently needed to help identify effective treatment strategies.

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“…However, in the present study, we applied a modified approach by continuously measuring LV pressure and volume during occlusion of the inferior vena cava to reduce RV volume and pressure for the short term. 22 This short-term reduction in RV volume removes external constraint to LV filling from the RV and pericardium. In the present study, we confirm that at least part of the short-term hemodynamic benefit of CRT in this population is due to a reduction in external constraint to LV filling.…”

Section: Discussionmentioning

confidence: 99%

Short-Term Hemodynamic Effects of Cardiac Resynchronization Therapy in Patients With Heart Failure, a Narrow QRS Duration, and No Dyssynchrony

et al. 2009

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Background-Cardiac resynchronization therapy produces both short-term hemodynamic and long-term symptomatic/ mortality benefits in symptomatic heart failure patients with a QRS duration Ͼ120 ms. This is conventionally believed to be due principally to relief of dyssynchrony, although we recently showed that relief of external constraint to left ventricular filling may also play a role. In this study, we evaluated the short-term hemodynamic effects in symptomatic patients with a QRS duration Ͻ120 ms and no evidence of dyssynchrony on conventional criteria and assessed the effects on contractility and external constraint. Methods and Results-Thirty heart failure patients (New York Heart Association class III/IV) with a left ventricular ejection fraction Յ35% who were in sinus rhythm underwent pressure-volume studies at the time of pacemaker implantation. External constraint, left ventricular stroke work, dP/dtmax, and the slope of the preload recruitable stroke work relation were measured from the end-diastolic pressure-volume relation before and during delivery of biventricular and left ventricular pacing. The following changes were observed during delivery of cardiac resynchronization therapy: Cardiac output increased by 25Ϯ5% (PϽ0.05), absolute left ventricular stroke work increased by 26Ϯ5% (PϽ0.05), the slope of the preload recruitable stroke work relation increased by 51Ϯ15% (PϽ0.05), and dP/dtmax increased by 9Ϯ2% (PϽ0.05). External constraint was present in 15 patients and was completely abolished by both biventricular and left ventricular pacing (PϽ0.05). Conclusion-Cardiac resynchronization therapy results in an improvement in short-term hemodynamic variables in patients with a QRS Ͻ120 ms related to both contractile improvement and relief of external constraint. These findings provide a potential physiological basis for cardiac resynchronization therapy in this patient population.

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Contribution of External Forces to Left Ventricular Diastolic Pressure: Implications for the Clinical Use of the Starling Law

Cited by 122 publications

References 0 publications

Left Ventricular Pacing Minimizes Diastolic Ventricular Interaction, Allowing Improved Preload-Dependent Systolic Performance

Left Ventricular Pacing Minimizes Diastolic Ventricular Interaction, Allowing Improved Preload-Dependent Systolic Performance

Heart Failure with Preserved Ejection Fraction

Short-Term Hemodynamic Effects of Cardiac Resynchronization Therapy in Patients With Heart Failure, a Narrow QRS Duration, and No Dyssynchrony

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