Prevalence of right ventricular dysfunction and prognostic significance in heart failure with preserved ejection fraction

Abstract

There is a paucity of data characterizing right ventricular performance in heart failure with preserved ejection fraction (HFpEF) using the gold standard of cardiovascular magnetic resonance imaging (CMR). We aimed to assess the proportion of right ventricular systolic dysfunction (RVD) in HFpEF and the relation to clinical outcomes. As part of a single-centre, prospective, observational study, 183 subjects (135 HFpEF, and 48 age- and sex-matched controls) underwent extensive characterization with CMR. transthoracic echocardiography, blood sampling and six-minute walk testing. Patients were followed for the composite endpoint of death or HF hospitalization. RVD (defined as right ventricular ejection fraction < 47%) controls was present in 19% of HFpEF. Patients with RVD presented more frequently with lower systolic blood pressure, atrial fibrillation, radiographic evidence of pulmonary congestion and raised cardiothoracic ratio and larger right ventricular volumes. During median follow-up of 1429 days, 47% (n = 64) of HFpEF subjects experienced the composite endpoint of death (n = 22) or HF hospitalization (n = 42). RVD was associated with an increased risk of composite events (Log-Rank p = 0.001). In multivariable Cox regression analysis, RVD was an independent predictor of adverse outcomes (adjusted Hazard Ratio [HR] 3.946, 95% CI 1.878–8.290, p = 0.0001) along with indexed extracellular volume (HR 1.742, CI 1.176–2.579, p = 0.006) and E/E’ (HR 1.745, CI 1.230–2.477, p = 0.002). RVD as assessed by CMR is prevalent in nearly one-fifth of HFpEF patients and is independently associated with death and/or hospitalization with HF.The trial was registered retrospectively on ClinicalTrials.gov (Identifier: NCT03050593). The date of registration was February 06, 2017.

Influence of Right Ventricular Dysfunction on Outcomes of Left Ventricular Non-compaction Cardiomyopathy

“…Further development of RV remodeling and myocardial fibrosis (29) may lead to right heart impairment, thus forming a vicious circle. In a previous cohort of individuals with heart failure with preserved LVEF, significant fluid overload and lower cardiac output were observed in the RV dysfunction subgroup (30). This could result in severe venous congestion and lower SBP, which allows greater requirements for vasoactive medications, all of which contribute to not only increased mortality due to rapid hemodynamic deterioration but also higher rates of acute kidney injury (31,32).…”

Microvascular Dysfunction in Heart Failure with Preserved Ejection Fraction: Pathophysiology, Assessment, Prevalence and Prognosis

“…right ventricular dysfunction, LA dysfunction, focal and diffuse myocardial fibrosis) known to influence prognosis. [9][10][11]60 CMR also permits quantitative perfusion assessment with greater spatial resolution than that of PET. In a study of 19 patients with symptomatic HFpEF (LVEF threshold >45%) and in whom LV hypertrophy was absent and CAD excluded by CT coronary angiography, MVD (defined as MPR <2.5) was present in the most (13/19).…”

“…8 Although left ventricular (LV) diastolic dysfunction is the predominant feature, additional elements include left atrial (LA) dysfunction, right ventricular dysfunction, focal and diffuse myocardial fibrosis and ventricular-arterial stiffening. [9][10][11][12] Currently, the pathophysiology of HFpEF remains to be fully elucidated, and the heterogeneity of disease mechanisms and their relative importance at an individual patient level may further confound treatment approaches. Aside from the recent positive evidence base for the use of Microvascular Dysfunction in Heart Failure with Preserved Ejection Fraction: Pathophysiology, Assessment, Prevalence and Prognosis sodium-glucose cotransporter 2 inhibitors, there remains a lack of treatment options with established prognostic benefit.…”

The role of cardiac magnetic resonance imaging in the assessment of heart failure with preserved ejection fraction

“…CMR is also the gold standard non-invasive method to assess right ventricular (RV) size and function. In a prospective, observational study the prevalence of RV dysfunction (RVEF < 47%) as determined by CMR was present in 19% of individuals with HFpEF ( n = 135) ( 71 ). Furthermore, RV dysfunction was independently associated with death and HF hospitalization (adjusted HR 3.946, 95% CI 1.878–8.290, p = 0.0001).…”