Early return of reflected waves increases right ventricular wall stress in chronic thromboembolic pulmonary hypertension

Masafumi Fukumitsu, Berend E. Westerhof, Dieuwertje Ruigrok, Natalia J. Braams, Joanne A. Groeneveldt, Ahmed A. Bayoumy, J. Tim Marcus, Lilian J. Meijboom, Frances S. de Man, Nico Westerhof, Harm Jan Bogaard, Anton Vonk Noordegraaf*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

6 Citations (Scopus)


Pulmonary vascular resistance (PVR) and compliance are comparable in proximal and distal chronic thromboembolic pulmonary hypertension (CTEPH). However, proximal CTEPH is associated with inferior right ventricular (RV) adaptation. Early wave reflection in proximal CTEPH may be responsible for altered RV function. The aims of the study are as follows: 1) to investigate whether reflected pressure returns sooner in proximal than in distal CTEPH and 2) to elucidate whether the timing of reflected pressure is related to RV dimensions, ejection fraction (RVEF), hypertrophy, and wall stress. Right heart catheterization and cardiac MRI were performed in 17 patients with proximal CTEPH and 17 patients with distal CTEPH. In addition to the determination of PVR, compliance, and characteristic impedance, wave separation analysis was performed to determine the magnitude and timing of the peak reflected pressure (as %systole). Findings were related to RV dimensions and time-resolved RV wall stress. Proximal CTEPH was characterized by higher RV volumes, mass, and wall stress, and lower RVEF. While PVR, compliance, and characteristic impedance were similar, proximal CTEPH was related to an earlier return of reflected pressure than distal CTEPH (proximal 53 ± 8% vs. distal 63 ± 15%, P < 0.05). The magnitude of the reflected pressure waves did not differ. RV volumes, RVEF, RV mass, and wall stress were all related to the timing of peak reflected pressure. Poor RV function in patients with proximal CTEPH is related to an early return of reflected pressure wave. PVR, compliance, and characteristic impedance do not explain the differences in RV function between proximal and distal CTEPH.

Original languageEnglish
Pages (from-to)1438-1450
Number of pages13
JournalAmerican Journal of Physiology - Heart and Circulatory Physiology
Issue number6
Publication statusPublished - Dec 2020


  • Pulmonary hypertension
  • Right ventricle afterload
  • Right ventricular wall stress
  • Wave reflection
  • n/a OA procedure


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