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. 2016 Sep 1:218:206-211.
doi: 10.1016/j.ijcard.2016.05.015. Epub 2016 May 13.

Imaging right ventricular function to predict outcome in pulmonary arterial hypertension

Melanie J Brewis  1 , Alessandro Bellofiore  2 , Rebecca R Vanderpool  3 , Naomi C Chesler  4 , Martin K Johnson  5 , Robert Naeije  6 , Andrew J Peacock  5
Affiliations

Imaging right ventricular function to predict outcome in pulmonary arterial hypertension

Melanie J Brewis et al. Int J Cardiol. .

Abstract

Background: Right ventricular (RV) function is a major determinant of outcome in pulmonary arterial hypertension (PAH). However, uncertainty persists about the optimal method of evaluation.

Methods: We measured RV end-systolic and end-diastolic volumes (ESV and EDV) using cardiac magnetic resonance imaging and RV pressures during right heart catheterization in 140 incident PAH patients and 22 controls. A maximum RV pressure (Pmax) was calculated from the nonlinear extrapolations of early and late systolic portions of the RV pressure curve. The gold standard measure of RV function adaptation to afterload, or RV-arterial coupling (Ees/Ea) was estimated by the stroke volume (SV)/ESV ratio (volume method) or as Pmax/mean pulmonary artery pressure (mPAP) minus 1 (pressure method) (n=84). RV function was also assessed by ejection fraction (EF), right atrial pressure (RAP) and SV.

Results: Higher Ea and RAP, and lower compliance, SV and EF predicted outcome at univariate analysis. Ees/Ea estimated by the pressure method did not predict outcome but Ees/Ea estimated by the volume method (SV/ESV) did. At multivariate analysis, only SV/ESV and EF were independent predictors of outcome. Survival was poorer in patients with a fall in EF or SV/ESV during follow-up (n=44, p=0.008).

Conclusion: RV function to predict outcome in PAH is best evaluated by imaging derived SV/ESV or EF. In this study, there was no added value of invasive measurements or simplified pressure-derived estimates of RV-arterial coupling.

Keywords: Pressure–volume relationship; Prognosis; Pulmonary hypertension; Right ventricular dysfunction.

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Conflict of interest statement

Dr Bellofiore, Dr Vanderpool, Dr Chesler and Professor Naeije report no relationships that could be construed as a conflict of interest.

Figures

Figure 1
Figure 1
Kaplan Meier survival curves describing survival rates of PAH patients stratified by [a] SV/ESV ≤ 0.534 and [b] RVEF > 32.5%. p values 0.017 and 0.040 respectively.
Figure 2
Figure 2
Serial CMR variables for 21 PAH patients performed at diagnosis, 3–8 months and 12–18 months after initiating PAH therapy. median (IQR) or mean (SD) shown. p value in comparison to baseline * p<0.05 ** p<0.01 *** p<0.001 [a]. SV/ESV [b] RVEF [d] SVI increased at 3–8months and were maintained at 12–18 months, one way ANOVA p = 0.006, p = 0.002 and p <0.001 respectively; [c] RVESVI fell at 3–8 months but was unchanged at 12–18 months, ANOVA p = 0.07; no change in RVEDVI occurred (data not shown). RVEF: right ventricular ejection fraction; SV/ESV: RV coupling volumetric method; RVESVI: right ventricular end systolic volume index; RVEDVI: right ventricular end diastolic volume index; SVI: stroke volume index.
Figure 3
Figure 3
Kaplan Meier curve describing survival of PAH patients with decrease in SV/ESV (n= 13) or stable/increased SV/ESV (n=31) at follow up.
See this image and copyright information in PMC

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