Prognostic Value of Pulmonary Vascular Resistance by Magnetic Resonance in Systolic Heart Failure

Abstract

BackgroundPulmonary hypertension is associated with poor prognosis in heart failure. However, non-invasive diagnosis is still challenging in clinical practice.ObjectiveWe sought to assess the prognostic utility of non-invasive estimation of pulmonary vascular resistances (PVR) by cardiovascular magnetic resonance to predict adverse cardiovascular outcomes in heart failure with reduced ejection fraction (HFrEF).MethodsProspective registry of patients with left ventricular ejection fraction (LVEF) < 40% and recently admitted for decompensated heart failure during three years. PVRwere calculated based on right ventricular ejection fraction and average velocity of the pulmonary artery estimated during cardiac magnetic resonance. Readmission for heart failure and all-cause mortality were considered as adverse events at follow-up.Results105 patients (average LVEF 26.0 ±7.7%, ischemic etiology 43%) were included. Patients with adverse events at long-term follow-up had higher values of PVR (6.93 ± 1.9 vs. 4.6 ± 1.7estimated Wood Units (eWu), p < 0.001). In multivariate Cox regression analysis, PVR ≥ 5 eWu(cutoff value according to ROC curve) was independently associated with increased risk of adverse events at 9 months follow-up (HR2.98; 95% CI 1.12-7.88; p < 0.03).ConclusionsIn patients with HFrEF, the presence of PVR ≥ 5.0 Wu is associated with significantly worse clinical outcome at follow-up. Non-invasive estimation of PVR by cardiac magnetic resonance might be useful for risk stratification in HFrEF, irrespective of etiology, presence of late gadolinium enhancement or LVEF.

Exercise-induced cardio-pulmonary remodelling in endurance athletes: Not only the heart adapts

“…It is accepted that the combination of raised pulmonary pressures and RV dysfunction suggests that the contractile reserve is struggling to maintain output against an increased afterload, and, indeed, previous studies have shown that it entails a poor prognosis. 31–33 The finding of a PVR >5 WU in patients with heart failure and reduced LVEF, quantified by the same method 15 we used, was recently associated with an increased risk of adverse events at nine months of follow-up. 33…”

“…31–33 The finding of a PVR >5 WU in patients with heart failure and reduced LVEF, quantified by the same method 15 we used, was recently associated with an increased risk of adverse events at nine months of follow-up. 33…”

“…Although these studies 31–33 have shown the prognostic impact of increased PVR in patients with systolic heart failure, there is currently no evidence of its potential prognostic significance in healthy and asymptomatic athletes. We did not find any significant relationship between increased estimated PVR and myocardial fibrosis or oxygen consumption data, which in turn indicates that higher estimated PVR did not impact athletes' training conditions.…”

“…To estimate PVR, we employed a CMR model validated in a small cohort of patients with pulmonary hypertension, 15 which showed good limits of agreement with PVR quantified by right heart catheterization. It has also been used subsequently in the setting of experimental pulmonary hypertension and clinically, and its prognostic significance has been demonstrated in patients with heart failure; 33,34 nonetheless, the estimation of PVR has not been validated using right heart catheterization in healthy patients. Despite this, in our cohort, data from echocardiography were also in line with findings of CMR: direct and indirect echocardiographic estimates of pulmonary pressure were significantly different and suggestive of higher pulmonary pressures in individuals with a higher CMR-estimated PVR, as per instance a higher tricuspid regurgitation V max .…”

Functional Tricuspid Regurgitation: Behind the Scenes of a Long-Time Neglected Disease

“…The CMR-derived model was estimated as: pulmonary vascular resistance [in Wood units (WUs)] = 19.38 – [4.62 × Ln pulmonary artery average velocity (in cm/s)] – [0.08 × RV ejection fraction (in %)] ( 24 ). This CMR method to noninvasively estimate pulmonary vascular resistance has been used in patients with PH and also in patients with heart failure and reduced LV ejection fraction (EF), in whom pulmonary vascular resistance > 5 WU was associated with an increased risk of adverse events at 9 months follow-up ( 38 , 39 ). Based on all this, we believe that this CMR method could also be integrated in the global evaluation of the RV in the setting of FTR in order to better understand if the RV contractile reserve is struggling to maintain output against an increased afterload, a finding which, indeed, previous studies have shown that entails a poor prognosis ( 39 ).…”