Diagnosis and management of pulmonary hypertension associated with left ventricular diastolic dysfunction

Abstract

Pulmonary hypertension (PH) is commonly seen in patients who present with left ventricular diastolic dysfunction (LVDD) and is considered a marker of poor prognosis. While PH in this setting is thought to result from pulmonary venous congestion, there is a subset of patients in which pulmonary pressures fail to improve with appropriate management of diastolic heart failure and go on to develop a clinical picture similar to that of patients with pulmonary arterial hypertension (PAH). Despite the utility of Doppler echocardiography and exercise testing in the initial evaluation of patients with suspected PH-LVDD, the diagnosis can only be confirmed using right heart catheterization. Management of PH-LVDD centers on both optimizing fluid management and afterload reduction to reducing left ventricular diastolic pressures and also increase pulmonary venous return. To date, there is no clear evidence that addition of PH-specific drugs can improve clinical outcomes, and their use should only be considered in the setting of clinical trials. In conclusion, PH-LVDD remains a challenging clinical entity that complicates the management of left ventricular dysfunction and significantly contributes to its morbidity and mortality. Determination of the optimal diagnostic and treatment strategies for this form of PH should be the goal of future studies.

Keywords: congestive heart failure; echocardiography; hemodynamics; pulmonary hypertension; therapeutics.

Figure 1

Survival of patients with PH-LVDD is inversely correlated to degree of pulmonary artery systolic pressure (PASP) elevation (Adapted from Lam et al[14]).

Figure 2

Echocardiographic findings in PH-LVDD. (A) Measurement of passive left ventricular filling during diastole (E) and active filling following left atrial contraction (A). In the setting of LVDD, ventricular filling by left atrial contraction becomes prominent and the E/A ratio is reversed (B) Distended left atrium and (C) increased tricuspid regurgitation jet in a patient with PH-LVDD.

Figure 3

Hemodynamic profile of a patient with PH-LVDD. (A) Patient demonstrates a mean pulmonary artery pressure (in magenta) of approximately 70 mmHg in the setting of a pulmonary capillary wedge pressure (in magenta) of approximately 20 mmHg (B).