Ventricular interaction: from bench to bedside

Decreased right ventricle (RV) output results in decreased left ventricle e nd-diastolic volume (LVEDV) and output by series interaction. Direct ventri cular interaction may also have a major effect on LV function. Thus, decrea sed LVEDV caused by reduced RV output may be further reduced by a leftward septal shift and pericardial constraint. This has been shown to be true in acute and chronic pulmonary hypertension and is now also apparent in severe congestive heart failure. The use of intracavitary LV end-diastolic pressu re (LVEDP) to assess LVEDV is inappropriate if pressure surrounding the LV is increased: the surrounding pressure should be subtracted from LVEDP to c alculate the effective distending (transmural) pressure which governs prelo ad. If the surrounding pressure increases more than LVEDP, transmural LVEDP and LVEDV will decrease despite the increased LVEDP. Thus, the use of fill ing pressure to reflect changes in LVEDV has led to erroneous conclusions r egarding changes in myocardial compliance and contractility. It is now clea r that volume loading may reduce LVEDV and stroke work in pulmonary embolis m, chronic lung disease and severe congestive heart failure despite increas ed LVEDP, The decreased stroke work is a result of reduced LV preload, not decreased contractility as would be suggested if filling pressure is used t o reflect preload.