Ventricular-Arterial Coupling, Remodeling, and Prognosis in Chronic Heart Failure

Abstract

Objectives The objective of this study was to compare the physiological determinants of ejection fraction (EF)—ventricular size, contractile function, and ventricular-arterial (VA) interaction—and their associations with clinical outcomes in chronic heart failure (HF). Background EF is a potent predictor of HF outcomes, but represents a complex summary measure that integrates several components including left ventricular size, contractile function, and VA coupling. The relative importance of each of these parameters in determining prognosis is unknown. Methods In 466 participants with chronic systolic HF, we derived quantitative echocardiographic measures of EF: cardiac size (end-diastolic volume [EDV]); contractile function (the end-systolic pressure volume relationship slope [Eessb] and intercept [V0]); and VA coupling (arterial elastance [Ea]/Eessb). We determined the association between these parameters and the following adverse outcomes: 1) the combined endpoint of death, cardiac transplantation, or ventricular assist device (VAD) placement; and 2) cardiac hospitalization. Results Over a median follow-up of 3.4 years, there were 76 deaths, 52 transplantations, 14 VAD placements, and 684 cardiac hospitalizations. EF was independently associated with death, transplantation, and VAD placement (adjusted hazard ratio [HR]: 3.0; 95% confidence interval [CI]: 1.8 to 5.0 comparing third and first tertiles), as were EDV (HR: 2.6; 95% CI: 1.5 to 4.2); V0 (HR: 3.6; 95% CI: 2.1 to 6.1); and Ea/Eessb (HR: 2.1; 95% CI: 1.3 to 3.3). EDV, V0, and Ea/Eessb were also associated with risk of cardiac hospitalization. Eessb was not significantly associated with any adverse outcomes in adjusted analyses. Conclusions Left ventricular size, V0, and VA coupling are associated with prognosis in systolic HF, but end-systolic elastance (Eessb) is not. Assessment of VA coupling via Ea/Eessb is an additional noninvasively derived metric that can be used to gauge prognosis in human HF.

Ventricular‐Arterial Function and Coupling in the Adult Fontan Circulation

“…Consistent with our data, the multicenter pediatric Fontan study showed that EF tended to decrease with increasing age and time post‐Fontan 2. Whereas the severity of ventricular remodeling and systolic dysfunction in the current cohort of clinically stable adult Fontan patients was less severe than that observed in similarly studied older adults with overt non‐CHD systolic HF,11 the impact of even mild systolic dysfunction may be significant in the Fontan circulation, particularly during exercise and may progress over time. Whether treatment with standard HF therapies used in non‐CHD HF patients with reduced EF would improve long‐term outcomes in adult Fontan patients remains an area of active investigation 1…”

“…A cardiac magnetic resonance imaging study showed widely varying EDV index and EF in Fontan patients relative to controls, but did not address the relationship between remodeling and ventricular function 26. The relationship between systolic dysfunction and eccentric remodeling is consistent with typical findings in non‐CHD HF 11. LV wall thickness in Fontan patients was, on average, within normal limits, but significantly higher than in control patients.…”

Ventricular-Arterial Coupling in Breast Cancer Patients After Treatment With Anthracycline-Containing Adjuvant Chemotherapy

“…If Anth-C increases Ea and/or reduces Ees by having a direct effect on the vasculature or myocardium, respectively, the reduction in Ea/Ees commonly observed with exercise will be greatly attenuated, indicative of reduced CVRC. Pathologic impairments in CVRC are etiologic in many chronic disease conditions [11], and surrogate measures of CVRC such as Ea/Ees are prognostic of mortality and cardiovascular events [12].…”

Effects of Cardiopulmonary Exercise Rehabilitation on Left Ventricular Mechanical Efficiency and Ventricular‐Arterial Coupling in Patients With Systolic Heart Failure

“…As cardiac function declines, arterial load increases to maintain systolic pressure and E es decreases, thus both lead to a decrease in this ratio representing inefficient contraction 22, 23, 24, 25, 26. Recently, this derangement has been shown to be strongly associated with adverse clinical outcomes in patients with heart failure irrespective of ejection fraction 16. To our knowledge, this is the first time that VAC is shown to be improved by cardiopulmonary rehabilitation in an unselected heart failure patient population.…”

“…Recently, with the introduction of noninvasive, single‐beat solutions for estimating E es ,15 it became possible to construct PV loop and assess VAC noninvasively. More important, it has been shown that VAC estimated by noninvasive methods is a strong predictor of prognosis in systolic heart failure 16. But, the effect of cardiac rehabilitation on VAC in unselected heart failure patients has not been studied thus far.…”