Low-Grade Diastolic Dysfunction Still Harms Left Ventricle Function, With Gregg Pressman, MD

Right ventricular end-diastolic volume and right ventricular ejection fraction (RVEF) have been heavily associated with left ventricular diastolic function, with even grade 1 diastolic dysfunction (DD) associated with a substantial drop in RVEF.1

Left heart failure (HF) has long been known to be a common cause of right HF. Increases in left atrial pressure result in reduced pulmonary artery compliance and increased right ventricular afterload, and left ventricular diastolic function is a critical determinant of left atrial pressure. Given this connection, DD was widely expected to affect right ventricle size and function.2

“We know that, when the left ventricle becomes stiff and a patient develops heart failure, the pressure of the heart rises, the pressure in the lungs rise, and the right ventricle can be enlarged and weakened,” Gregg Pressman, MD, professor of medicine in the division of cardiology, Jefferson Einstein Philadelphia Hospital, Thomas Jefferson University, told HCPLive in an exclusive interview. “What is less clear, and what we studied, is whether stiffening of the left side of the heart by itself causes abnormal function on the right half of the heart, even if the patient doesn’t have clinical signs and symptoms of heart failure.”

Pressman and colleagues enrolled 370 patients in the trial, all of whom were undergoing clinically indicated echocardiograms and had a 3D assessment of the right ventricle. Inpatients and outpatients were included; patients were excluded if they were younger than 18 years, had nongroup 2 pulmonary hypertension by World Health Organization classification, nonsinus rhythm at the time of echocardiography, or suboptimal 3D echocardiographic images.1

After imaging, patients were separated into groups based on diastolic function grade. The final data were based on the 2025 ASE algorithm, categorizing patients as having normal diastolic function or grades 1, 2, or 3 DD. Investigators compared 3D-derived right ventricle end-diastolic volume (RVEDV) and indexed RVEDV (RVEDVi) across diastolic grades, followed by comparing linear measurements of the right ventricle and the ratios of basal right ventricle diastolic dimension, mid-right ventricle diastolic dimension, and right ventricle diastolic longitudinal dimension.1

A regression analysis was then conducted to determine whether diastolic grade was an independent predictor of RVEDV and RVEF, controlling for age, sex, race, body surface area, and estimated systolic pulmonary artery pressure.1

Ultimately, for 21 subjects, the auto right ventricle software could not provide volumetric measurements. For another 22, it could not provide TAPSE or right ventricle linear dimensions. For the remainder, RVEDV and RVEDVi were similar between patients with normal diastolic function and grade 1 DD. However, grades 2 and 3 showed substantial increases in both measures of right ventricle diastolic size. Similarly, basal and midcavity dimensions were similar between normal and grade 1 DD, but increased for grade 2 and 3. However, longitudinal dimension showed no significant relationship with diastolic function grade.1

RVEF also showed a substantial decrease across diastolic function groups, irrespective of age, sex, race, body surface area, and systolic pulmonary arterial pressure. Notably, even grade 1 DD showed a significant decrease in RVEF compared to normal; indexed left and right atrial volumes were similar, but reservoir strain of each atrium was decreased in patients with grade 1 DD.1

Ultimately, Pressman and colleagues determined that left ventricular DD can produce right ventricular enlargement and cause right heart dysfunction. They attribute this in part to the backward effects of elevated left arterial pressure on the pulmonary vasculature, which are transmitted to the right heart. The trial also highlights the risk of even lesser degrees of left ventricular DD to the right heart.1

“Right now, we’re at an interesting time in cardiology – this type of heart failure, which is due to stiffening, finally has some effective treatments,” Pressman said. “For years, we did not have such treatments, and it’s an open question whether applying those treatments to patients who have stiffening but have not yet developed clinical heart failure might prevent enlargement and weakening of the right half of the heart.”

Editor’s Note: Pressman reports no relevant disclosures.

References

1. Almani MU, Romero AJ, Akuna E, et al. Impact of left ventricular diastolic function on right ventricular size and function. JASE. Published online January 2, 2026. doi:10.1016/j.echo.2025.12.015

2. Thomas L, Marwick TH, Popescu BA, Donal E, Badano LP. Left Atrial Structure and Function, and Left Ventricular Diastolic Dysfunction: JACC State-of-the-Art Review. J Am Coll Cardiol. 2019;73(15):1961-1977. doi:10.1016/j.jacc.2019.01.059