Abstract
BackgroundIn pulmonary arterial hypertension (PAH) increased afterload leads to adaptive processes of the right ventricle (RV) that help to maintain arterio-ventricular coupling of RV and preserve cardiac output, but with time the adaptive mechanisms fail. In this study, we propose a multimodal approach which allows to estimate prognostic value of RV coupling parameters in PAH patients.MethodsTwenty-seven stable PAH patients (49.5 ± 15.5 years) and 12 controls underwent cardiovascular magnetic resonance (CMR). CMR feature tracking analysis was performed for RV global longitudinal strain assessment (RV GLS). RV-arterial coupling was evaluated by combination of RV GLS and three proposed surrogates of RV afterload—pulmonary artery systolic pressure (PASP), pulmonary vascular resistance (PVR) and pulmonary artery compliance (PAC). 18-FDG positron emission tomography (PET) analysis was used to assess RV glucose uptake presented as SUVRV/LV. Follow-up time of this study was 25 months and the clinical end-point was defined as death or clinical deterioration.ResultsCoupling parameters (RV GLS/PASP, RV GLS/PVR and RV GLS*PAC) significantly correlated with RV function and standardized uptake value (SUVRV/LV). Patients who experienced a clinical end-point (n = 18) had a significantly worse coupling parameters at the baseline visit. RV GLS/PASP had the highest area under curve in predicting a clinical end-point and patients with a value higher than (−)0.29%/mmHg had significantly worse prognosis. It was also a statistically significant predictor of clinical end-point in multivariate analysis (adjusted R2 = 0.68; p < 0.001).ConclusionsCoupling parameters are linked with RV hemodynamics and glucose metabolism in PAH. Combining CMR and hemodynamic measurements offers more comprehensive assessment of RV function required for prognostication of PAH patients.Trial Registration: NCT03688698, 09/26/2018, retrospectively registered; Protocol ID: 2017/25/N/NZ5/02689
Highlights
Pulmonary arterial hypertension (PAH) is a progressive disease, in which declining right ventricular (RV) function with accompanying uncoupling to the pulmonary circulation is a turning point of clinical worsening
The concept of coupling mainly refers to the relationship between ventricular contractility and afterload alterations of this phenomenon may be an early marker of right ventricle (RV) failure [6]
According to 1-year mortality risk groups presented in European Society of Cardiology (ESC) guidelines [7], nineteen patients (70%) were at intermediate risk; five patients (19%) at low risk and three patients (11%) at high risk
Summary
Pulmonary arterial hypertension (PAH) is a progressive disease, in which declining right ventricular (RV) function with accompanying uncoupling to the pulmonary circulation is a turning point of clinical worsening. The gold standard to assess RV-arterial coupling requires invasive procedure to obtain pressure–volume loop-derived end-systolic elastance (Ees) to arterial elastances (Ea) ratio. This ratio (Ees/Ea) gives direct quantification of RV-arterial coupling [4]. Measuring these parameters via pressure–volume loops is technically demanding and cannot be performed routinely during regular PAH patients’ assessments. In pulmonary arterial hypertension (PAH) increased afterload leads to adaptive processes of the right ventricle (RV) that help to maintain arterio-ventricular coupling of RV and preserve cardiac output, but with time the adaptive mechanisms fail. We propose a multimodal approach which allows to estimate prognostic value of RV coupling parameters in PAH patients
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