Right ventricular dysfunction for prediction of long-term recovery in de novo HFrEF : a PROLONG-II substudy

Abstract

Aims: To analyse the predictive value of advanced markers of right ventricular (RV) function and RV-pulmonary arterial (PA) coupling in forecasting long-term left ventricular (LV) improvement in de novo heart failure with reduced ejection fraction (HFrEF).

Methods and results: 260 patients (mean age 57 years, 68% men) from the PROLONG-II study were included. PROLONG-II analysed patients with new-onset HFrEF receiving a wearable cardioverter-defibrillator. For this substudy, RV free wall longitudinal strain (RVFWS), tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and right ventricular-pulmonary artery (RV-PA) coupling ratios [RVFWS/systolic pulmonary artery pressure (PASP), TAPSE/PASP and FAC/PASP] at baseline and 3-month follow-up (early follow-up) were examined. LV improvement and non-improvement were defined as an LV ejection fraction (LVEF) of >35% or ≤35% at last available (long-term) follow-up. The median follow-up was 31.5 months (IQR: 18.2-45.4), and 151 (58%) patients experienced LV improvement in the long term. No significant differences of RV function and markers of RV-PA coupling were observed at baseline; however, the subgroup of patients with long-term LVEF improvement showed better RV function at early follow-up (RVFWS -20.9 ± 4.3 vs. -18.5 ± 5.1%, TAPSE 19.7 ± 5.1 vs. 17.4 ± 4.9 mm, FAC 39.7 ± 8.5 vs. 35.2 ± 9.4%, all P < 0.01). In multivariable analysis, RVFWS at early follow-up was shown to be an independent predictor of later LV recovery [odds ratio 1.078 (95% confidence interval 1.010-1.150), P < 0.05]. The non-improvers exhibited worse RV-PA coupling at early follow-up [RVFWS/PASP 0.82 ± 0.35 vs. 0.65 ± 0.35%/mmHg, TAPSE/PASP 0.71 (0.55-1.00) vs. 0.54 (0.35-0.75) mm/mmHg, FAC/PASP 1.54 ± 0.61 vs. 1.24 ± 0.75%/mmHg, all P < 0.01]. RVFWS/PASP identified RV-PA uncoupling was associated with a higher risk of all-cause mortality (hazard ratio 4.64, 95% confidence interval 1.34-16.09, P = 0.033).

Conclusions: Persistent RV dysfunction, as indicated by both standard and advanced echocardiographic markers during the early follow-up period, implies a reduced potential for long-term LV recovery in patients with newly diagnosed HFrEF.

Keywords: Heart failure; Right ventricular free wall longitudinal strain; Right ventricular function; Right ventricular‐pulmonary arterial coupling; Speckle‐tracking echocardiography.

Figure 1

LVEF changes in subgroups with and without RV‐PA uncoupling as evaluated by RVFWS/PASP at baseline, early 3‐month, and last available follow‐up. LVEF, left ventricular ejection fraction; RV, right ventricular, RVFWS/PASP, ratio between right ventricular free wall longitudinal strain and pulmonary artery systolic pressure.

Figure 2

Kaplan–Meier survival curves according to RV‐PA coupling. (A) Survival analysis according to RVFWS/PASP (cut‐offs >0.71 vs. ≤0.71%/mmHg). (B) Survival analysis according to TAPSE/PASP (cut‐offs ≥0.67 vs. <0.67 mm/mmHg). (C) Survival analysis according to FAC/PASP (cut‐offs >1.41 vs. ≤1.41%/mmHg). FAC/PASP, ratio between fractional area change and pulmonary artery systolic pressure; RVFWS/PASP, ratio between right ventricular free wall longitudinal strain and pulmonary artery systolic pressure; RV‐PA, right ventricular‐pulmonary artery; TAPSE/PASP, ratio between tricuspid annular plane systolic excursion ratio and pulmonary artery systolic pressure.