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. 2018 Oct;5(5):864-875.
doi: 10.1002/ehf2.12304. Epub 2018 Jun 19.

Increased right atrial volume measured with cardiac magnetic resonance is associated with worse clinical outcome in patients with pre-capillary pulmonary hypertension

Anna Bredfelt  1   2 , Göran Rådegran  3   4 , Roger Hesselstrand  5   6 , Håkan Arheden  1   2 , Ellen Ostenfeld  1   2
Affiliations

Increased right atrial volume measured with cardiac magnetic resonance is associated with worse clinical outcome in patients with pre-capillary pulmonary hypertension

Anna Bredfelt et al. ESC Heart Fail. 2018 Oct.

Abstract

Aims: Pre-capillary pulmonary hypertension (PHpre-cap ) has a poor prognosis, especially when caused by pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc-PAH). Whether cardiac magnetic resonance (CMR)-based quantification of atrial volumes in PHpre-cap is beneficial in risk assessment is unknown. The aims were to investigate if (i) atrial volumes using CMR are associated with death or lung transplantation in PHpre-cap , (ii) atrial volumes differ among four unmatched major PHpre-cap subgroups, and (iii) atrial volumes differ between SSc-PAH and idiopathic/familial PAH (IPAH/FPAH) when matched for pulmonary vascular resistance (PVR).

Methods and results: Seventy-five PHpre-cap patients (57 ± 19 years, 53 female, 43 de novo) with CMR and right heart catheterization were retrospectively included. Short-axis stacks of cine images were analysed, and right and left atrial maximum (RAVmax and LAVmax ) and minimum volume (RAVmin and LAVmin ) were indexed for body surface area. Increased (mean + 2 SD) and reduced (mean - 2 SD) volumes were predefined from CMR normal values. Transplantation-free survival was lower in patients with increased RAVmax than in those with normal [hazard ratio (HR) = 2.1, 95% confidence interval (CI) 1.1-4.0] but did not differ between those with reduced LAVmax and normal (HR 2.0, 95% CI 0.8-5.1). RAVmax and RAVmin showed no differences among unmatched or matched groups (P = ns). When matched for PVR, LAVmax , LAVmin , and pulmonary artery wedge pressure were reduced in SSc-PAH compared with IPAH/FPAH (95% CI 0.3-21.4, 95% CI 0.8-19.6, and 95% CI 2-7, respectively).

Conclusions: Patients with PHpre-cap and increased right atrial volume measured with CMR had worse clinical outcome. When matched for PVR, left atrial volume was lower in SSc-PAH than in IPAH/FPAH, consistent with left-sided underfilling, indicating a potential differentiator between the groups.

Keywords: Cardiac magnetic resonance imaging; Left atrial volume; Pulmonary hypertension; Right atrial volume; Transplantation-free survival.

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Figures

Figure 1
Figure 1
Transplantation‐free survival analyses of atrial volumes in pre‐capillary pulmonary hypertension. Kaplan–Meier transplantation‐free survival analysis of pre‐capillary pulmonary hypertension patients from timepoint of CMR. All volumes are indexed for body surface area. (A) Patients with normal right atrial maximal volume (RAVmax) (full line) compared with patients with increased RAVmax (dashed line). Hazard ratio (HR) for enlarged RAVmax was 2.1 (95% CI 1.1–4.0, P = 0.03). (B) Patients with normal left atrial maximal volume (LAVmax) (full) compared with patients with reduced LAVmax (dashed). HR for reduced LAVmax was 2.0 (95% CI 0.8–5.1, P = 0.07). (C) Patients with right atrial minimal volume (RAVmin) below median (full) compared with patients with RAVmin above median (dashed). HR for RAVmin above median was 2.3 (95% CI 1.2–4.3, P = 0.02). (D) Patients with left atrial minimal volume (LAVmin) above median (full) compared with patients with LAVmin below median (dashed). HR for LAVmin below median was 1.7 (95% CI 0.9–3.2, P = 0.12).
Figure 2
Figure 2
Comparison of atrial volumes, unmatched and matched for PVR. Tukey box plot showing comparison of atrial volumes among unmatched and matched subgroups of pre‐capillary pulmonary hypertension. All volumes are indexed for body surface area. (A–D) Right atrial volumes. (E–H) Left atrial volumes: left column, maximal volumes; right column, minimal volumes. (A, B, E, and F) Comparison among groups when unmatched for PVR. (C, D, G, and H) Comparison between groups when matched for PVR. RAVmax, right atrial maximal volume; RAVmin, right atrial minimal volume; IPAH/FPAH, idiopathic or familial pulmonary arterial hypertension; SSc‐PAH, pulmonary arterial hypertension associated with systemic sclerosis; CTD‐PAH, pulmonary arterial hypertension associated with connective tissue disorders; CTEPH, chronic thrombo‐embolic pulmonary hypertension; LAVmax, left atrial maximal volume; LAVmin, left atrial minimal volume; PVR, pulmonary vascular resistance.
Figure 3
Figure 3
Atrial volumes in relation to right atrial pressure, cardiac index, NT‐proBNP, and pulmonary artery wedge pressure. Correlation of atrial maximal volumes indexed for body surface area with invasive right atrial pressure (A), cardiac index (B and E), NT‐proBNP (C and F), and pulmonary artery wedge pressure (D) expressed with Spearman's correlation coefficient (r). Filled circles indicate patients without atrial fibrillation; open circles, patients with atrial fibrillation; asterisks, patients with atrial fibrillation excluded from analysis. (A–C) Right atrial maximal volumes. (D–F) Left atrial maximal volumes. RAVmax, right atrial maximal volume; LAVmax, left atrial maximal volume; RAP, right atrial pressure; CI, cardiac index; NT‐proBNP, N‐terminal pro‐brain natriuretic peptide; PAWP, pulmonary artery wedge pressure.
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