Cardiac magnetic resonance identifies raised left ventricular filling pressure: prognostic implications

Abstract

Aims Non-invasive imaging is routinely used to estimate left ventricular (LV) filling pressure (LVFP) in heart failure (HF). Cardiovascular magnetic resonance (CMR) is emerging as an important imaging tool for sub-phenotyping HF. However, currently, LVFP cannot be estimated from CMR. This study sought to investigate (i) if CMR can estimate LVFP in patients with suspected HF and (ii) if CMR-modelled LVFP has prognostic power. Methods and results Suspected HF patients underwent right heart catheterization (RHC), CMR and transthoracic echocardiography (TTE) (validation cohort only) within 24 h of each other. Right heart catheterization measured pulmonary capillary wedge pressure (PCWP) was used as a reference for LVFP. At follow-up, death was considered as the primary endpoint. We enrolled 835 patients (mean age: 65 ± 13 years, 40% male). In the derivation cohort (n = 708, 85%), two CMR metrics were associated with RHC PCWP:LV mass and left atrial volume. When applied to the validation cohort (n = 127, 15%), the correlation coefficient between RHC PCWP and CMR-modelled PCWP was 0.55 (95% confidence interval: 0.41–0.66, P < 0.0001). Cardiovascular magnetic resonance-modelled PCWP was superior to TTE in classifying patients as normal or raised filling pressures (76 vs. 25%). Cardiovascular magnetic resonance-modelled PCWP was associated with an increased risk of death (hazard ratio: 1.77, P < 0.001). At Kaplan–Meier analysis, CMR-modelled PCWP was comparable to RHC PCWP (≥15 mmHg) to predict survival at 7-year follow-up (35 vs. 37%, χ2 = 0.41, P = 0.52). Conclusion A physiological CMR model can estimate LVFP in patients with suspected HF. In addition, CMR-modelled LVFP has a prognostic role.

Cardiac magnetic resonance left ventricular filling pressure is linked to symptoms, signs and prognosis in heart failure

“…Even prior studies that evaluated the integrated approach demonstrate modest diagnostic reliability of echocardiography for LVFP 23 . In our previous work, where we recruited 127 participants who underwent CMR, echocardiography, and invasive assessment, echocardiography‐derived LVFP was indeterminate in 49% of participants 6 . And, of those participants where echocardiography was non‐diagnostic (indeterminate or incorrect diagnosis), CMR was able to correctly reclassify participants to either ‘normal’ or ‘raised’ LVFP in 71% cases.…”

“…The current study differs from the large CMR‐derived LVFP study that initially validated CMR against invasive methods 6 . This study reports completely different clinical outcomes in patients with HF, namely, hospitalization from decompensated HF and MACE, vs. all‐cause mortality as the clinical outcome within the validation study.…”

“…In a recent observational study involving 835 participants, a CMR-derived model to estimate LVFP was developed and validated by RHC performed within 24 h. 6 The CMR-derived LVFP model originates from a single-centre study and needs to be validated in external cohorts of subjects with HF. 7 This study aimed to test CMR-derived LVFP in a real-world population of patients undergoing CMR to identify the aetiology of HF.…”

Editorial for “Corrected MRI Pulmonary Transit Time for Identification of Combined Pre and PostCapillary Pulmonary Hypertension in Patients With Left Heart Disease”

“…A physiological model based on two simple CMR metrics-left atrial volume and left ventricular mass-has recently been shown to provide an accurate estimation of PAWP in patients with suspected heart failure (HF), largely outperforming transthoracic echocardiography and delivering prognostic implications that were non-inferior to invasive RHC. 6 In a cohort of 708 patients with suspected PH who underwent same-day CMR and RHC, an end-systolic interventricular septal angle >160 enabled the identification of CpcPH with 67% sensitivity and 93% specificity. 7 Beyond geometric indices of cardiac remodeling, central circulation metrics by firstpass CMR perfusion imaging, such as pulmonary transit time (PTT) and pulmonary blood volume, have recently gained attention as quantitative biomarkers of HF reflective of the magnitude of left ventricular filling pressures retrogradely transmitted to the pulmonary circulation, with increased PAWP as a major determinant in prolonged PTT.…”

“…There is a growing interest for wider use of cardiovascular magnetic resonance (CMR) in PH assessment as a highly robust and accurate modality for volumetric, functional, structural, and hemodynamic phenotyping of the cardiovascular system. A physiological model based on two simple CMR metrics—left atrial volume and left ventricular mass—has recently been shown to provide an accurate estimation of PAWP in patients with suspected heart failure (HF), largely outperforming transthoracic echocardiography and delivering prognostic implications that were non‐inferior to invasive RHC 6 . In a cohort of 708 patients with suspected PH who underwent same‐day CMR and RHC, an end‐systolic interventricular septal angle >160° enabled the identification of CpcPH with 67% sensitivity and 93% specificity 7 .…”