Comprehensive cardiac magnetic resonance assessment of right ventricular and left atrial function for early diagnosis of heart failure with preserved ejection fraction

Abstract

Objectives: To investigate the role of right ventricular (RV) maladaptive response to increased afterload in the early diagnosis of heart failure with preserved ejection fraction (HFpEF) using cardiac magnetic resonance (CMR) and invasive cardiopulmonary exercise testing (iCPET). This study evaluates biventricular function and its association with exercise performance in HFpEF.

Materials and methods: We prospectively recruited 145 patients with suspected HFpEF from two centers, of whom 113 underwent echocardiography, iCPET, and CMR. Patients met the 2016 European Society of Cardiology HFpEF criteria, with iCPET confirming HFpEF as a pulmonary capillary wedge pressure (PCWP) > 15 mmHg at rest and > 25 mmHg at peak exercise. The diagnostic performance of CMR parameters was assessed using the area under the curve (AUC).

Results: Among the 113 patients, 72 had HFpEF (68 ± 10 years) and 41 were non-HFpEF (66 ± 11 years). HFpEF patients exhibited significantly reduced resting pulmonary artery compliance. CMR-derived RV longitudinal strain and left atrial (LA) reservoir strain had the highest diagnostic accuracy for HFpEF (AUC 0.805 and 0.776, respectively). A sex disparity was observed in the LA reservoir strain's diagnostic performance, with higher accuracy in males (AUC 0.801) compared to females (AUC 0.559). Additionally, impaired LA reservoir and booster strains, correlated with reduced exercise capacity and increased PCWP during exercise, highlighting their clinical relevance.

Conclusions: RV systolic dysfunction and impaired LA strain serve as early HFpEF markers. The more pronounced LA dysfunction in males suggests potential sex-specific differences, underscoring the need to integrate RV and LA strain assessment into HFpEF diagnostics and personalized treatment approaches.

Key points: Question Can cardiac MRI (CMR)-derived RV strain and LA reservoir strain improve the early diagnosis of HFpEF in symptomatic patients with preserved ejection fraction? Findings CMR-derived RV longitudinal strain and LA reservoir strain effectively differentiate early HFpEF; diagnostic accuracy of LA strain varies significantly by sex. Clinical relevance CMR-based RV and LA strain measurements enhance early HFpEF detection, with higher diagnostic accuracy in males, supporting sex-specific diagnostic strategies for timely and personalized heart failure care.

Keywords: Atrial function (left); Cardiac imaging (magnetic resonance); Heart failure (diastolic); Sex factors; Ventricular function (right).