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Am J Physiol Heart Circ Physiol (October 16, 2009). doi:10.1152/ajpheart.00870.2009
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00870.2009v1
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Submitted on September 11, 2009
Revised on October 5, 2009
Accepted on October 13, 2009

Right Ventricular Free Wall Pacing Improves Cardiac Pump Function in Severe Pulmonary Arterial Hypertension: a Computer Simulation Analysis

Joost Lumens1*, Theo Arts1, Bernard Broers2, Karin A. Boomars2, Pieter van Paassen2, Frits W. Prinzen1, and Tammo Delhaas1

1 Maastricht University
2 University Hospital Maastricht

* To whom correspondence should be addressed. E-mail: j.lumens{at}fys.unimaas.nl.

In pulmonary arterial hypertension (PAH), duration of myofiber shortening is prolonged in the right ventricular (RV) free wall (RVfw) as compared to that in the interventricular septum and left ventricular (LV) free wall (LVfw). This interventricular mechanical asynchrony eventually leads to right heart failure. We investigated by computer simulation whether, in PAH, early RVfw pacing may improve interventricular mechanical synchrony and, hence, cardiac pump function. A mathematical model of the human heart and circulation was used to simulate LV and RV pump mechanics and myofiber mechanics. First, we simulated cardiovascular mechanics of a healthy adult at rest. Size and mass of heart and blood vessels were adapted so that mechanical tissue load was normalized. Second, compensated PAH was simulated by increasing mean pulmonary artery pressure (mPAP) to 32 mmHg while applying load adaptation. Third, decompensated PAH was simulated by increasing mPAP further to 79 mmHg without further adaptation. Finally, early RVfw pacing was simulated in severely decompensated PAH. Time courses of circumferential strain in the ventricular walls as simulated were similar to the ones measured in healthy subjects (uniform strain patterns) and in PAH patients (prolonged RVfw shortening). When simulating pacing in decompensated PAH, RV pump function was best upon 40 ms RVfw pre-excitation, as evidenced by maximal decrease of RV end-diastolic volume, reduced RVfw myofiber work, and most homogeneous distribution of workload over the ventricular walls. Thus, our simulations indicate that, in decompensated PAH, RVfw pacing may improve RV pump function and may homogenize workload over the ventricular walls.







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