Prognostic value of mean velocity at the pulmonary artery estimated by cardiovascular magnetic resonance as a prognostic predictor in a cohort of patients with new-onset heart failure with reduced ejection fraction

Trejo-Velasco et al. Journal of Cardiovascular Magnetic Resonance https://doi.org/10.1186/s12968-020-00621-3 RESEARCH ARTICLE (2020) 22:28 Open Access Prognostic value of mean velocity at the pulmonary artery estimated by cardiovascular magnetic resonance as a prognostic predictor in a cohort of patients with new-onset heart failure with reduced ejection fraction Blanca Trejo-Velasco1*, Óscar Fabregat-Andrés2, Pilar M. García-González3, Diana C. Perdomo-Londoño4, Andrés M. Cubillos-Arango4, Mónica I. Ferrando-Beltrán4, Joaquina Belchi-Navarro4, José L. Pérez-Boscá4, Rafael Payá-Serrano4 and Francisco Ridocci-Soriano4 Abstract Background: Pulmonary hypertension (PH) conveys a worse prognosis in heart failure (HF), in particular when right ventricular (RV) dysfunction ensues. Cardiovascular magnetic resonance (CMR) non-invasively estimates pulmonary vascular resistance (PVR), which has shown prognostic value in HF. Importantly, RV to pulmonary artery (PA) coupling is altered early in HF, before significant rise in PV resistance occurs. The aim of this study was to assess the prognostic value of mean velocity at the pulmonary artery (mvPA), a novel non-invasive parameter determined by CMR, in HF with reduced ejection fraction (HFrEF) with and without associated PH. Methods: Prospective inclusion of 238 patients admitted for new-onset HFrEF. MvPA was measured with CMR during index admission. The primary endpoint was defined as a composite of HF readmissions and all-cause mortality. Results: During a median follow-up of 25 months, 91 patients presented with the primary endpoint. Optimal cut-off value of mvPA calculated by the receiver operator curve for the prediction of the primary endpoint was 9 cm/s. The primary endpoint occurred more frequently in patients with mvPA≤9 cm/s, as indicated by Kaplan-Meier survival curves; Log Rank 16.0, p < 0.001. Importantly, mvPA maintained its prognostic value regardless of RV function and also when considering mortality and HF readmissions separately. On Cox proportional hazard analysis, reduced mvPA≤9 cm/s emerged as an independent prognostic marker, together with NYHA III-IV/IV class, stage 3–4 renal failure and ischemic cardiomyopathy. (Continued on next page) * Correspondence: ; 1 Cardiology Department, Hospital Clínico de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo San Vicente 182, 37007 Salamanca, Spain Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Trejo-Velasco et al. Journal of Cardiovascular Magnetic Resonance (2020) 22:28 Page 2 of 13 (Continued from previous page) Conclusions: In our HFrEF cohort, mvPA emerged as an independent prognostic indicator independent of RV function, allowing identification of a higher-risk population before structural damage onset. Moreover, mvPA emerged as a surrogate marker of the RV-PA unit coupling status. Keywords: HFrEF, Cardiac MRI, Right ventricle, Ventricular-arterial coupling, Prognosis, pulmonary hypertension Background Pulmonary hypertension (PH) is a frequent comorbid condition associated with heart failure (HF) [1], which implies a worse prognosis [2], in particular when right ventricular (RV) dysfunction ensues [3]. Although right heart catheterisation (RHC) is the gold standard technique for PH diagnosis, it entails certain risk of peri-procedural complications as well as radiation exposure. As a result, there is growing interest in PH evaluation by non-invasive procedures such as echocardiography and cardiovascular magnetic resonance (CMR) [4, 5]. CMR is an especially attractive diagnostic tool in this setting, as it provides accurate structural and functional assessment of the cardiac chambers –in particular the RV, which plays a determinant role in the prognosis of PH and HF [6]. CMR also assesses other parameters of the pulmonary circulation such as pulmonary artery (PA) pulsatility and mean velocity at the pulmonary artery (mvPA), which correlate strongly with mean pulmonary artery pressure (mPAP) in PH− [7]. In recent years, increasing evidence supporting a comprehensive evaluation of the right ventricular-pulmonary artery (RV-PA) unit that integrates RV function and its adaptation to loading conditions is emerging [8, 9]. Importantly, RV-PA coupling not only encompasses the static component of RV afterload, expressed by pulmonary vascular resistance (PVR) [10, 11], but also its pulsatile element, which is altered at earlier disease stages in HF [12–14]. Accordingly, inefficient RV-PA coupling can be detected promptly and acts as a reliable prognostic indicator [15, 16]. In clinical practice, several RV-PA coupling indicators such as CMR derived Emax/Ea ratio, tricuspid annular plane systolic excursion (TAPSE) to systolic PA pressure (sPAP) and PA stiffness and compliance are employed to stratify prognosis in PH and HF patients [15, 17–19], as direct measurement of end-systolic elastance (Emax, index of contractility) and PA effective elastance (Ea, index of arterial load) to calculate RV-PA coupling is complex and requires an invasive assessment of the right heart chambers to construct pressure–volume loops [8]. Recently, prognostic value of mvPA has been described in in a small sample of patients with HF with reduced (HFrEF) and intermediate ejection fraction (HFmEF) [20]. In this study we assessed the prognostic value of mvPA in a cohort of patients with new-onset HFrEF with and without associated PH. In addition, we evaluated the potential role of mvPA as a surrogate marker of the RV-PA unit coupling state. Methods Study population Between January 2013 and January 2017, 238 consecutive patients (64.1 ± 12.6 years, 72% male) were prospectively included during their admission for acute newonset HFrEF in the Cardiology Deptartment of a tertiary care hospital. Seventy patients included in a prior publication investigating mvPA in HF were al (...truncated)