Left Ventricular-Arterial Coupling in Cardiovascular Health: Development, Assessment Methods, and Future Directions

doi:10.37015/AUDT.2024.240057

Abstract

Abstract:

Left ventricular-arterial coupling (LVAC) represents a critical physiological mechanism that characterizes the interaction between left ventricular (LV) contractility and the arterial system's resistance and elasticity. The balance within LVAC is essential for efficient energy transfer from the heart, which underpins optimal cardiovascular function. In a healthy state, the balance between LV contractility and arterial elasticity and resistance allows the heart to maintain normal circulation with minimal energy expenditure. However, with the progression of age and diseases such as atherosclerosis and hypertension, arterial stiffness increases, LV function decreases, and the LVAC balance is disrupted, leading to a significantly increased risk of cardiovascular events. This imbalance is particularly significant in patients with heart failure (HF) and coronary artery disease (CAD), where LVAC imbalance is strongly associated with increased cardiac load and decreased energy efficiency. Thus, understanding and evaluating LVAC are crucial for elucidating cardiovascular physiology and guiding therapeutic strategies for diseases such as HF, hypertension, and CAD. Methods for assessing LVAC include invasive pressure-volume loops and cardiac catheterization, as well as non-invasive techniques such as echocardiography and arterial pulse wave analysis (PWA). Despite the higher accuracy of invasive methods, non-invasive methods are commonly used in clinical practice to assess LVAC because of their lower risk. With cardiac magnetic resonance imaging (CMR) and 3D/4D imaging techniques advancing, more precise structural and functional analysis of the heart and arterial system will be possible in the future. In this review, we describe the physiological mechanisms, assessment methods, influencing factors, and clinical significance of LVAC, as well as interdisciplinary studies with biomechanics and metabolism, which provide new ideas for personalized treatment of LVAC.

Key words: Echocardiography; Left ventricular-arterial coupling; Cardiovascular; Arterial stiffness; Cardiac function

Chen Anni, Yang Lan, Li Zhenyi, Wang Xinqi, Chen Ya, Jin Lin, Li Zhaojun. Left Ventricular-Arterial Coupling in Cardiovascular Health: Development, Assessment Methods, and Future Directions. Advanced Ultrasound in Diagnosis and Therapy, 2024, 8(4): 159-171.

Figures/Tables 4

Figure 1

Table 1

Table 2

Advantages and disadvantages of left ventricular-arterial coupling assessment methods"

Assessment modality	Advantages	Disadvantages
Cardiac catheterization [13]	Direct measurement of pressure and volume enables accurate assessment of coupling conditions Real-time assessment of LV function and arterial load The gold standard for assessing Ees and Ea	Highly invasive, with risks including infection, bleeding, and other complications Costly
Pressure-volume loop [70,71]	Accurate assessment of cardiac function Assess changes in the heart under different loading conditions	Highly invasive and may cause complications Technically complex and costly
PWA [72-75]	A non-invasive examination with low risk Ease of operation, suitable for large-scale population screening and follow-up	Direct assessment of LV function is more limited Results are more influenced by the measurement site and technical maneuvers May not be as accurate as invasive methods
Echocardiography [20,76,77]	Non-invasive, convenient, and inexpensive Suitable for assessing LV function in a variety of clinical settings Provide additional information on cardiac structure and function (such as EF and myocardial strain rate).	Highly influenced by operator skill level and imaging conditions Indirect estimation of Ees and Ea may be subject to some error
CMR [21-23]	Non-invasive imaging techniques Accurate measurement of the three-dimensional structure and function of the heart Very high imaging resolution High precision and reliability	Higher costs Long inspection time Restrictive to patients (such as cannot be used in patients with metal implants)
AI, ML [28,29]	Saves data processing time, improves the efficiency of assessments Enable greater accuracy and consistency in complex clinical environments Provide personalized LVAC prediction and treatment recommendations	Based on computer models, not yet validated in clinical models Requires very advanced and expensive computer equipment

Table 2

Table 3

Advantages and disadvantages of left ventricular-arterial coupling evaluation metrics"

Evaluation metrics	Advantages	Disadvantages
Ventricular afterload
Ea	A key indicator of ventricular afterload Accurately reflecting the compliance and resistance of the arterial system	Usually requires invasive or semi-invasive measurements and is not applicable to all patients, especially in acute situations Susceptible to significant influences of heart rate and is not a pure index of arterial load Complex to calculate Depends mainly on resistance and is not sensitive to changes in pulsatile arterial load
Aortic impedance	Reflects the dynamic interaction between the heart and the arterial system, and is an accurate assessment of ventricular afterload Closely related to the compliance, elasticity, and other characteristics of the cardiovascular system, and can be used to assess atherosclerosis and other pathologies	Complex to measure, often requiring invasive or sophisticated measurement tools such as pressure catheters and ultrasonic devices More sensitive to hydrodynamic conditions and may be affected by changes in heart rate and hemodynamics
SVR	Assesses the total resistance of blood vessels to pumping by the heart and is suitable for assessing overall hemodynamic Easy to calculate, commonly measured by hemodynamic monitoring tools, and quick to use in acute situations	Only reflects overall resistance, not arterial elasticity or microvascular resistance accurately Insensitive to small vessel disease or local arterial stiffness
Arterial blood pressure (especially MAP )	Widely used, simple and without complex equipment	Inability to accurately assess the true state of afterload, especially to reflect changes in the elasticity of the arterial system
Myocardial contractility
Ees	A direct indicator of myocardial contractility Can be accurately measured by pressure-volume loops	Requires invasive equipment and has limited clinical application Does not assess myocardial properties (only "ventricular" properties) Measurement complexity Little validation of single beat non-invasive methods beyond original derivation studies
Maximum left ventricular pressure	A direct measure of cardiac contractility and provides an assessment of LV function during systole Can be used to analyze patients with impaired cardiac function, especially those with hypertension and HF Provide personalized LVAC prediction and treatment recommendations	Requires invasive testing equipment (cardiac catheterization) and cannot be routinely applied clinically Only provides information on the highest pressure and does not fully reflect the dynamics of the entire systolic period
Maximum rate of left ventricular pressure change (dP/dt)	Reflects the strength of myocardial contraction capacity, which is a direct indicator of cardiac contractile function Dynamically reflects the performance of myocardial contraction in the early stages, suitable for real-time monitoring	Sensitive to preload and afterload, need to combine with other indicators to comprehensively assess cardiac function
EF	Non-invasive and suitable for a wide range of clinical settings	Insensitivity to subtle changes in myocardial contractility

Table 3

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Year	Author	Research finds
1920s	Otto Frank Ernest Starling [1]	Established the theoretical foundation for the interaction between cardiac function and vascular system, known as the "Frank-Starling law", which elucidates the relationship between cardiac output and arterial compliance.
1974	Suga Sagawa [2]	Introduced the pressure-volume relationship model, which characterizes the alignment between LV contractility and the arterial system.
1981	Sagawa [69]	The concept of ESPVR, one of the core metrics for studying LVAC, was proposed.
1983	Sunagawa [4]	VAC was further developed, and Ea and Ees were proposed for evaluating the coupling of the LV and arterial systems.
1980s (1983)	Sunagawa with his colleagues [4]	VAC was further investigated and subdivided into LVAC and RVAC, a phase of research that greatly advanced the understanding of the pathophysiologic mechanisms of cardiovascular diseases (such as HF, hypertension).
1992	Kelly Ting [9]	Explored Ea as a marker of arterial load, marking the initial clinical application of the LVAC concept.
2013	Chirinos [10]	LVAC is widely used to assess pathologies such as HF, CAD, and hypertension. Therapeutic strategies to help clinicians optimize cardiac function.