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Right ventricular–pulmonary artery coupling in chronic thromboembolic pulmonary hypertension
  1. Aleksandra Bartnik1,2,3,
  2. Joanna Pepke-Zaba4,
  3. Stephen P Hoole5,
  4. Paul White6,7,
  5. Madalina Garbi5,
  6. John G Coghlan5,
  7. Fouad Taghavi3,
  8. Steven Tsui3,
  9. Jonathan Weir-McCall1,2
  1. 1Radiology, Royal Papworth Hospital, Cambridge, UK
  2. 2University of Cambridge, Cambridge, UK
  3. 3Surgery, Royal Papworth Hospital, Cambridge, UK
  4. 4Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
  5. 5Cardiology, Royal Papworth Hospital, Cambridge, UK
  6. 6Medical Physics and Clinical Engineering, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  7. 7Medical Technology Research Centre, Anglia Ruskin University, Cambridge, UK
  1. Correspondence to Dr Aleksandra Bartnik, Royal Papworth Hospital, Cambridge, UK; o.bartnik{at}


Chronic thromboembolic pulmonary hypertension occurs in a proportion of patients with prior acute pulmonary embolism and is characterised by breathlessness, persistently raised pulmonary pressures and right heart failure. Surgical pulmonary endarterectomy (PEA) offers significant prognostic and symptomatic benefits for patients with proximal disease distribution. For those with inoperable disease, management options include balloon pulmonary angioplasty (BPA) and medical therapy. Current clinical practice relies on the evaluation of pulmonary haemodynamics to assess disease severity, timing of and response to treatment. However, pulmonary haemodynamics correlate poorly with patient symptoms, which are influenced by right ventricular tolerance of the increased afterload. How best to manage symptomatic patients with chronic thromboembolic pulmonary disease (CTEPD) in the absence of pulmonary hypertension is not resolved.

Right ventricular–pulmonary artery coupling (RV-PAC) describes the energy transfer within the whole cardiopulmonary unit. Thus, it can identify the earliest signs of decompensation even before pulmonary hypertension is overt. Invasive measurement of coupling using pressure volume loop technology is well established in research settings. The development of efficient and less invasive measurement methods has revived interest in coupling as a viable clinical tool. Significant improvement in RV-PAC has been demonstrated after both PEA and BPA. Further studies are required to understand its clinical utility and prognostic value, in particular, its potential to guide management in patients with CTEPD. Finally, given the reported differences in coupling between sexes in pulmonary arterial hypertension, further work is required to understand the applicability of proposed thresholds for decoupling in therapeutic decision making.

  • Magnetic Resonance Imaging
  • echocardiography
  • cardiac catheterization
  • hypertension, pulmonary
  • pulmonary embolism

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  • Contributors All authors had substantial contributions to the manuscript conception, revision, final approval and ensuring accuracy of the information presented according to ICMJE guidelines (see further details). AB: primary role in conception and design, review of existing literature, writing of the manuscript and creation of table and figures. JP-Z: major role in conception and design, review of literature for the manuscript, revision and final approval, ensuring of the accuracy of the information presented. SPH: major role in conception, review of the literature for the manuscript (particularly the invasive method review), revision and final approval. PW: review of the literature (particularly the invasive methods review), revision and final approval. MG: review of the literature (particularly echo-based methods), revision and final approval. JGC: review of the literature (particularly the invasive methods review), revision and final approval. FT and ST: revision and ensuring of the accuracy of information pertaining to CTEPH and particularly surgical management aspect and final approval. JW-M: senior author, primary role in manuscript conception, design, literature review, revision and final approval.

  • Funding This work was supported by JP Moulton Charity Trust (grant number 01/19) and NIHR Cambridge Biomedical Research Centre (grant number BRC-1215-20014).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.