Multimodal assessment of right ventricular-arterial coupling allows better prognostication in pulmonary arterial hypertension patients

Abstract Background The concept of coupling mainly refers to the relationship between ventricular contractility and afterload. Together, strictly related parameters may provide a more accurate estimation of the RV performance status. Indexing RV function, assessed by CMR feature tracking analysis, with a pulmonary artery systolic pressure (PASP) obtained from right heart catheterization (RHC) allows estimation of ventricular-arterial coupling and could help in prognostic stratification of pulmonary arterial hypertension (PAH) patients. Aim To verify the prognostic value of multimodal approach to estimate RV ventricular-arterial coupling in PAH patients. Methods Twenty-six stable PAH patients (mean age 49.92±15.94 years) and twelve healthy subjects (control group, 44.75±13.51 years) were enrolled into the study. CMR feature tracking analysis of the RV was performed for generation of RV global longitudinal strain (RV GLS); RV ejection fraction was also obtained by CMR. Right heart catheterization was carried out only in the PAH group with a standard technique.RV- arterial coupling was evaluated by the ratio of RV GLS/PASP. Mean follow-up time of this study was 16.6±7.5 months and the clinical end-point (CEP) was defined as death or clinical deterioration. Results In study group, RV GLS significantly correlated with hemodynamic parameters from RHC – mean pulmonary artery pressure, mPAP (r=0.53, p=0.04) and pulmonary vascular resistance, PVR (r=0.57, p=0.002). Mean RV GLS/PASP ratio in PAH group was (−)0.24±0.15%/mmHg. Patients who reached CEP (n=15) had a significantly higher RV GLS and RV GLS/PASP ratio (−13.3±7.9% vs −20.4±6.2%, p=0.01 and −0.15±0.09%/mmHg vs −0.36±0.19%/mmHg, p=0.005, respectively). However, ROC analysis revealed higher area under curve (AUC) of RV GLS/PASP in predicting CEP than of RV GLS alone (0.82 (95% CI 0.64–1) vs 0.77 (95% CI 0.58–0.96), p<0.0001). Interestingly, at univariate analysis only RV GLS/PASP (HR: 0.89; 95% CI: 0.79–1.08; p=0.03), together with mPAP were all significantly associated with CEP. Patients with RV GLS/PASP cut-off value (ROC analysis) higher than (−)0.29%/mmHg had worse prognosis, log-rank test, p=0.01 (Figure 1). Figure 1 Conclusions Combining CMR and hemodynamic measurements via catheterization offers the potential for more comprehensive assessment of pulmonary vascular load and right heart function, as required for evaluation of the hemodynamic state in patients with PAH. Acknowledgement/Funding This work was supported by National Center for Science in Poland [“Preludium” grant 2017/25/N/NZ5/02689 to R.K.]