Outcome in Heart Failure with Preserved Ejection Fraction: The Role of Myocardial Structure and Right Ventricular Performance

Abstract

BackgroundHeart failure with preserved ejection fraction (HFpEF) is recognized as a major cause of cardiovascular morbidity and mortality. Thus, a profound understanding of the pathophysiologic changes in HFpEF is needed to identify risk factors and potential treatment targets in this specific patient population. Therefore, we aimed to comprehensively assess the impact of left- and right-ventricular function and hemodynamics on long-term mortality and morbidity in order to improve risk prediction in patients with HFpEF.Methods and ResultsWe prospectively included 142 consecutive patients with HFpEF into our observational, non-interventional registry. Echocardiography, cardiac magnetic resonance imaging and invasive hemodynamic assessments including myocardial biopsy were performed at baseline. We detected significant correlations between left ventricular extracellular matrix and left ventricular end-diastolic diameter (r = -0.64;p = 0.03) and stroke volume (r = -0.53;p = 0.04). Hospitalization for heart failure and/or cardiac death was observed over a median follow up of 10 months. The strongest risk factors were reduced right ventricular function (adj. HR 6.62;95%CI 3.12- 14.02;p<0.001), systolic pulmonary arterial pressure (adj. HR per 1-SD 1.55;95%CI 1.15- 2.09;p = 0.004) and the pulmonary artery wedge pressure (adj. HR per 1-SD 1.51;95%CI 1.09–2.08; p = 0.012). The area under the ROC curve for right ventricular function was 0.63, for systolic pulmonary arterial pressure 0.75, and for pulmonary artery wedge pressure 0.68.ConclusionThe current study emphasizes the importance of right ventricular function and pulmonary pressures on outcome in patients with HFpEF providing pathophysiological insights into the hemodynamic changes in HFpEF.

Interstitial Fibrosis, Functional Status, and Outcomes in Heart Failure With Preserved Ejection Fraction

“…In line with recent publications, [29][30][31][32] several parameters were associated with adverse outcome, such as pulmonary arterial pressures, serum NT-proBNP levels, severity of symptoms, and parameters of right ventricular dysfunction. We observed significant correlations of MOLLI-ECV with these clinically important parameters.…”

Functional Status, Pulmonary Artery Pressure, and Clinical Outcomes in Heart Failure With Preserved Ejection Fraction

“…The prognosis-limiting role of RV contractile impairment and RV afterload was also confirmed by Melenovsky et al (12). In addition to the aforementioned studies, our group complemented RV assessment by invasive hemodynamic measurements in 142 patients with HFpEF and emphasized the relevance of RVD and pulmonary vascular disease on outcomes (11). Furthermore, our group recently showed that RVD, assessed by magnetic resonance imaging, was independently associated with cardiac events (14).…”

“…It is broadly accepted that hemodynamic parameters, determined mainly by LV function, during systole and/or diastole, are associated with the severity of exercise impairment in patients with HF (9,10). Our group and others have recently drawn attention to the right ventricle and its prognosis-limiting role in HFpEF (11)(12)(13)(14). Parameters of right ventricular function (RVF) as well as those reflecting right ventricular (RV) afterload have not been examined in the context of physical activity so far.…”

The Role of Cardiovascular Magnetic Resonance Imaging in Heart Failure

“…140,141 While 2D-echocardiography has superior temporal resolution for assessment of LV filling, CMR may contribute superior assessment of LVEF, LV mass and LA volumes, in addition to correlates of pulmonary hypertension (e.g. pulmonary artery:aorta ratio 142 and RV function 143 ). The use of correlations between diastolic dysfunction and diffuse myocardial fibrosis 144 and between post-contrast T1 and outcome 145 is under investigation and CMR indices of diastolic function are not yet routinely measured.…”