Prognostic Relevance of Pulmonary Arterial Compliance in Patients With Chronic Heart Failure

doi:10.1378/chest.13-1510

Chest

Volume 145, Issue 5, May 2014, Pages 1064-1070

https://doi.org/10.1378/chest.13-1510 Get rights and content

Background

Reduced pulmonary arterial compliance (Ca) is a marker of poor prognosis in idiopathic pulmonary arterial hypertension. We tested the hypothesis that pulmonary arterial Ca could be a predictor of outcome in patients with chronic heart failure (CHF).

Methods

We enrolled 306 patients with CHF due to systolic left ventricular dysfunction (sLVD) who underwent a clinically driven right-sided heart catheterization. Pulmonary arterial Ca was measured by the ratio between stroke volume and pulse pressure (SV/PP). The primary end point was cardiovascular death; secondary end point was the composite of cardiovascular death, urgent heart transplantation, and appropriately detected and treated episode of ventricular fibrillation.

Results

An inverse relationship was observed between SV/PP and pulmonary vascular resistance, the mean resistance-compliance product (RC-time) being 0.30 ± 0.2 s. In patients with pulmonary capillary wedge pressure (PCWP) < 15 mm Hg, the mean RC-time was 0.34 ± 0.14 s, and in patients with PCWP ≥ 15 mm Hg it was 0.28 ± 0.22 s. Eighty-seven patients died in a follow-up period of 50 ± 32 months. At receiver operating characteristic curve analysis, the optimal prognostic cutoff point of SV/PP was 2.15 mL/mm Hg. An elevated (> 2.15) SV/PP was more strongly associated with survival than any other hemodynamic variable; it was associated with poor prognosis both in patients with high (P = .003) and in patients with normal pulmonary vascular resistance (P = .005).

Conclusions

Pulmonary arterial Ca is a strong prognostic indicator in patients with CHF with sLVD. Most importantly, its prognostic role is retained in patients with normal pulmonary vascular resistance.

Section snippets

Study Patients

The study included 306 consecutive patients with CHF with sLVD, referred for heart failure management, heart transplantation evaluation, or both. The inclusion criteria were left ventricular ejection fraction ≤ 35% and etiology due to ischemic or hypertensive heart disease or idiopathic dilated cardiomyopathy. Exclusion criteria were organic valvular heart disease, previous surgery for valvular heart disease, other cardiomyopathies (such as restrictive or hypertrophic cardiomyopathy and

Results

Table 1 shows the main demographic, clinical, hemodynamic, and echocardiographic characteristics of the entire population. The study included young patients, mainly affected by dilated cardiomyopathy, with advanced sLVD at echocardiography and reduced cardiac output at right-sided heart catheterization.

Discussion

To our knowledge, this is the first study aiming at verifying the hemodynamic correlates and the prognostic implications of a reduced pulmonary arterial Ca in patients with sLVD with normal or elevated PVR. The main result of the present study is that a reduced pulmonary arterial Ca portends a poor prognosis independently of other well-known right-sided heart hemodynamic variables and that its negative prognostic impact is retained even in patients with normal PVR.

A reduced pulmonary arterial

Acknowledgments

Author contributions: Dr Ghio is the guarantor of the content of the manuscript, including the data and analysis.

Dr Pellegrini: contributed to conception of the study, interpretation of data, revision of the manuscript critically for important intellectual content, and final approval of the version to be published.

Dr Rossi: contributed to conception of the study, interpretation and analysis of data, revision of the manuscript critically for important intellectual content, and final approval of

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Indeed, there is a huge potential in therapeutic interference with mechano-associated pathways in vascular fibrosis and stiffening. The most direct approach is aiming to restore extracellular matrix homeostasis, by interference with its production, deposition, modification and turnover. Besides structural cells, immune cells contribute to the level of ECM maturation and degradation by direct cell-cell contact or the release of mediators and proteases, thereby opening a huge avenue to target vascular fibrosis via immunomodulation approaches. Indirectly, intracellular pathways associated with altered mechanobiology, ECM production, and fibrosis, offer a third option for therapeutic intervention. In PH, a vicious cycle of persistent activation of mechanosensing pathways such as YAP/TAZ initiates and perpetuates vascular stiffening, and is linked to key pathways disturbed in PH, such as TGF-β/BMPR2/STAT.
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Right ventricular failure (RVF) due to an acute myocardial infarction (MI) has been associated with high morbidity and mortality. Initial treatment is guided by early recognition and prompt revascularization. Current management of post-MI RVF is built upon expert consensus and is also informed by RVF from other etiologies, including massive pulmonary embolism, left ventricular assist device–associated right ventricular dysfunction, postcardiotomy shock, etc.; this speaks to the limited data available on the specific management of RVF in acute MI. The goal of this review is to discuss the current literature on the pathophysiology, general management considerations, interventional management, hemodynamic monitoring, medical management, and mechanical circulatory support of MI-induced RVF.
Comparative Prognostic Value of Parameters of Pulsatile Right Ventricular Afterload in Patients With Advanced Heart Failure Awaiting Heart Transplantation
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Right ventricular pulsatile afterload (RVPA) demonstrated a strong impact on survival of patients with advanced heart failure (HF) with reduced ejection fraction. The best prognostic parameter of RVPA is unknown. The aim of this work was to examine the prognostic relevance of pulmonary artery compliance (PAC), pulmonary artery elastance (PAE), and pulmonary artery pulsatile index (PAPi) in a consecutive cohort of patients with advanced HF evaluated for heart transplantation (HT).
A total of 149 patients with end-stage HF underwent right-sided cardiac catheterization and were clinically followed up until death or any censoring events, including HT, left ventricular assist device, and hospitalization for acute HF. The primary endpoint occurred in 29 patients (19.5%) during a median follow-up time of 12 (interquartile range 3 to 34) months. This cohort presented a worse hemodynamic profile than event-free survivors. PAC <1.9 mL/mm Hg (hazard ratio 3, 95% confidence interval 1.3 to 6.0, p= 0.007) and PAE >0.9 mmHg/mL (hazard ratio 2.5, 95% confidence interval 1.1 to 5.2, p= 0.02) were associated with the adverse outcome. On the contrary, PAPi was not associated with the outcome. PAC demonstrated a superior predictive value for the composite adverse outcome compared with pulmonary vascular resistance (area under the curve comparison p= 0.019) and PAPi (p= 0.03) but similar compared with PAE (p= 0.19) and mean pulmonary arterial pressure (p= 0.51). PAC, but not PAE, showed incremental prognostic value compared with cardiac index (p= 0.02). In conclusion, hemodynamic indexes of RVPA are associated with worse survival in patients with end-stage HF. PAC and PAE demonstrated superior prognostic value compared with PAPi and pulmonary vascular resistance. Moreover, PAC showed incremental prognostic value compared with cardiac index in patients awaiting HT.
When Pulmonary Hypertension Complicates Heart Failure
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Right heart catheterization in advanced systolic heart failure. What are the most useful haemodynamic parameters for risk stratification?
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Citation Excerpt :
There are several reasons to explain these discordant results, namely selected populations, different endpoints and multicollinearity. Previous studies have analysed the impact of haemodynamic parameters in selected populations, either in SHF patients [7,25] or in patients on the waiting list for heart transplantation [16,19], with the exclusion of severe patients contraindicated for heart transplantation. Some analyses were restricted to patients with reversible PH [27,29].
Previous studies have shown that pulmonary hypertension is a predictor of mortality in patients with systolic heart failure (SHF). Persistent pulmonary hypertension after a reactivity test is associated with a worse outcome after transplantation. Recent studies have shown the utility of different haemodynamic parameters.
To define best haemodynamic parameters for risk stratification in patients with advanced systolic heart failure.
We included 425 consecutive patients who underwent a right heart catheterization with an inotropic challenge if indicated.
During a median (interquartile range) follow-up of 1.67 (0.49–4.49) years, there were 151 major cardiac events (126 cardiovascular deaths and 25 postoperative deaths after ventricular assist device implantation or heart transplantation). The most powerful independent predictors of major cardiac events were baseline right atrial pressure (RAP) (hazard ratio [HR]: 1.09, 95% confidence interval [CI]: 1.06–1.12; P < 0.0001) and baseline pulmonary vascular resistance (PVR) (HR: 1.10; 95% CI: 1.03–1.17; P = 0.002). After inotropic challenge, the only independent predictor was mean pulmonary arterial pressure (mPAP) (HR: 1.06; 95% CI: 1.03–1.09; P < 0.0001). The combination of PVR (≤ or > 3 Wood units), RAP (< or ≥ 9 mmHg) and mPAP after the inotropic challenge (≤ or > 30 mmHg) was the best predictor of major events.
We suggest using a simple algorithm based on baseline PVR, baseline RAP and mPAP after the inotropic challenge for the risk stratification of stable patients with advanced systolic heart failure.
Des études précédentes ont démontré que l’hypertension pulmonaire prédisait la mortalité chez les patients avec une insuffisance cardiaque systolique. Une hypertension pulmonaire persistante après un test de réactivité est associée à plus d’événements après une transplantation. Des études récentes ont montré l’intérêt de différents paramètres hémodynamiques.
Définir les paramètres hémodynamiques les plus puissants pour la stratification du risque des patients en insuffisance cardiaque systolique avancée.
Nous avons inclus 425 patients consécutifs qui ont eu un cathétérisme cardiaque droit avec un test aux inotropes si nécessaire.
Pendant un suivi médian (écart interquartile) de 1,67 (0,49–4,49) ans, il y a eu 151 événements cardiaques majeurs (126 décès cardiovasculaires et 25 décès postopératoires après soit l’implantation d’une assistance ventriculaire soit une transplantation). Les paramètres prédicteurs indépendants les plus puissants étaient la pression auriculaire droite (POD) (hazard ratio [HR] : 1,09 ; intervalle de confiance à 95 % [IC95 %] : 1,06–1,12 ; p < 0,0001) et les résistances vasculaires pulmonaires (RVP) (HR : 1,10 ; IC95 % : 1,03–1,17 ; p = 0,002). Sous inotropes, le seul paramètre indépendant était la pression pulmonaire moyenne (mPAP) (HR : 1,06 ; IC95 % : 1,03–1,09 ; p < 0,0001). La combinaison des RVP (≤ ou > 3 unités Wood), de la POD (< ou ≥ 9 mmHg) et de la mPAP sous inotropes (≤ ou > 30 mmHg) était le prédicteur le plus puissant des événements cardiovasculaires majeurs.
On suggère l’utilisation d’un algorithme simple basé sur les RVP et la POD en base et la mPAP sous inotropes pour la stratification du risque des patients stables avec une insuffisance cardiaque systolique avancée.
Increased Pulmonary Arterial Compliance after Balloon Pulmonary Angioplasty Predicts Exercise Tolerance Improvement in Inoperable CTEPH Patients with Lower Pulmonary Arterial Pressure
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Balloon pulmonary angioplasty (BPA) improved pulmonary arterial compliance (C_PA) and exercise tolerance in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH).
To investigate whether C_PA is a useful index to indicate exercise tolerance improvement by BPA in CTEPH patients.
The correlation between changes in C_PA and improvements in 6-minute walk distance (6MWD) by BPA was retrospectively analyzed in 70 patients (Analysis 1), and it was sequentially analyzed in 46 symptomatic patients who achieved mean pulmonary arterial pressure (mPAP)<30mmHg (Analysis 2).
We enrolled 70 patients (female/male:57/13, mean age:59 years) who underwent a total of 352 BPA sessions which significantly increased C_PA (1.5±0.8 vs. 3.0±1.0 mL/mmHg) and decreased pulmonary vascular resistance (PVR) (8.0 ± 3.9 vs. 3.6 ± 1.7 wood units). The correlation coefficient between improvement in 6MWD and changes in PVR and C_PA were r=0.21 (p=0.09) and r=0.14 (p=0.26) (Analysis 1). In Analysis 2, those were r=0.32 (p=0.06) and r=0.38 (p=0.02), respectively.
C_PA can be a useful index to indicate the improvement in exercise tolerance by BPA in symptomatic patients with lower mPAP.

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Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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Chest

Original ResearchPrognostic Relevance of Pulmonary Arterial Compliance in Patients With Chronic Heart Failure

Background

Methods

Results

Conclusions

Section snippets

Study Patients

Results

Discussion

Acknowledgments

J Am Coll Cardiol

Chest

Chest

J Am Coll Cardiol

Int J Cardiol

J Am Coll Cardiol

JACC: Heart Failure

Pulmonary hypertension and risk of death in cardiomyopathy: patients with myocarditis are at higher risk

Circulation

Prognostic relevance of a non-invasive evaluation of right ventricular function and pulmonary artery pressure in patients with chronic heart failure

Eur J Heart Fail

Right ventricular function and failure: report of a National Heart, Lung, and Blood Institute working group on cellular and molecular mechanisms of right heart failure

Circulation

Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure

Circulation

Original Research
Prognostic Relevance of Pulmonary Arterial Compliance in Patients With Chronic Heart Failure