Prognostic value of mean velocity at the pulmonary artery estimated by cardiovascular magnetic resonance as a prognostic predictor in a cohort of patients with new-onset heart failure with reduced ejection fraction

Abstract

Background Pulmonary hypertension (PH) conveys a worse prognosis in heart failure (HF), in particular when right ventricular (RV) dysfunction ensues. Cardiovascular magnetic resonance (CMR) non-invasively estimates pulmonary vascular resistance (PVR), which has shown prognostic value in HF. Importantly, RV to pulmonary artery (PA) coupling is altered early in HF, before significant rise in PV resistance occurs. The aim of this study was to assess the prognostic value of mean velocity at the pulmonary artery (mvPA), a novel non-invasive parameter determined by CMR, in HF with reduced ejection fraction (HFrEF) with and without associated PH. Methods Prospective inclusion of 238 patients admitted for new-onset HFrEF. MvPA was measured with CMR during index admission. The primary endpoint was defined as a composite of HF readmissions and all-cause mortality. Results During a median follow-up of 25 months, 91 patients presented with the primary endpoint. Optimal cut-off value of mvPA calculated by the receiver operator curve for the prediction of the primary endpoint was 9 cm/s. The primary endpoint occurred more frequently in patients with mvPA≤9 cm/s, as indicated by Kaplan-Meier survival curves; Log Rank 16.0, p < 0.001. Importantly, mvPA maintained its prognostic value regardless of RV function and also when considering mortality and HF readmissions separately. On Cox proportional hazard analysis, reduced mvPA≤9 cm/s emerged as an independent prognostic marker, together with NYHA III-IV/IV class, stage 3–4 renal failure and ischemic cardiomyopathy. Conclusions In our HFrEF cohort, mvPA emerged as an independent prognostic indicator independent of RV function, allowing identification of a higher-risk population before structural damage onset. Moreover, mvPA emerged as a surrogate marker of the RV-PA unit coupling status.

Mean Velocity of the Pulmonary Artery as a Clinically Relevant Prognostic Indicator in Patients with Heart Failure with Preserved Ejection Fraction

“…Previous studies have reported on the value of mvPA in HFrEF and HFmEF [12,13]. However, to the best of our knowledge, this is the first one to ascertain its prognostic role in patients with HFpEF.…”

“…Indeed, abnormal RV to PC coupling develops in early phases in HF, before PVR rises, as a result of reduced PA compliance and increased PA stiffness [23]. Accordingly, an integral assessment of RV function relative to its load, i.e., RV to PC coupling, has recently emerged as a strong prognostic predictor in HF as well as in PH [7][8][9][10][11][12]26,27].…”

“…Recently, several monocentric studies have reported on the potential value of the mean velocity of the pulmonary artery (mvPA) determined by cardiac magnetic resonance (CMR) as a novel non-invasive surrogate of the RV-PC coupling unit, with prognostic value in HF with reduced (HFrEF) and mid-range ejection fraction (HFmEF) [12,13]. Unlike other indexes of RV-PC coupling, the mvPA is not directly calculated from RV stroke volume nor RV ejection fraction (RVEF) and could allow for further prognostic stratification both in patients with and without associated RV dysfunction.…”

A clinically relevant prognostic indicator of heart failure with mildly reduced ejection fraction is the mean velocity of the pulmonary artery

“…There have been numerous studies describing the prognostic value of PVR estimated by CMR in the assessment of HF with suspected PH over the last few years (25,26) .As a result, PA compliance and stiffness are altered in patients with HF at an early stage of the disease, before a signi cant increase in PVR is achieved.The reductions in the PA compliance and PA stiffness result in an ine cient RV-PA coupling and have emerged as strong, early prognostic indicators for this clinical scenario (27) .The evidence presented above prompted us to investigate the potential role of mvPA as a surrogate marker of the RV-PA coupling state,as mvPA provides information on both RV function and RV afterload.It was found that patients with mvPA below the threshold value of 9.05cm/s had worse PA-RV coupling, as demonstrated by lower RVEF and lower TAPSE/SPAP ratios.Taking these data into account, mvPA appears to play a critical role in assessing RV-PA coupling. Of note, mvPA outperformed the RV-PA coupling indicators we utilized.The TAPSE/SPAP ratio is calculated based on a comparison of the RV function and the PASP estimation obtained during echocardiography.Among our sample of patients, mvPA performed better in terms of prognoses than both indices of RV-PA coupling and that TAPSE/PASP,which have also been associated with higher PA pressures and worse prognoses in a variety of conditions aside from HF.…”

Novelties in Pulmonary Hypertension Secondary to Left Heart Disease

“…This opens the possibility of PA hemodynamic estimation and monitoring in a non-invasive manner, particularly in patients with poor acoustic window, that could help to reduce the number of repeated RHC procedures during follow-up. Moreover, prognostic value CMR-estimated PVR has been reported in patients with chronic HF 84,85 .…”