1Medizinische Hochschule Hannover Kardiologie und Angiologie Hannover, Deutschland
Background: Early identification of myocardial recovery potential is crucial for the management of device therapy in patients with newly diagnosed heart failure (HF). It is unclear if advanced measures of right ventricular (RV) function can be used to forecast long-term left ventricular (LV) recovery in new onset HF. This study aimed to examine the predictive value of RV free wall longitudinal strain (RVFWS) and parameters of RV-pulmonary arterial (PA) coupling in forecasting the long-term LV improvement in patients with newly diagnosed HF with reduced ejection fraction (HFrEF).
Methods: The study included patients from the PROLONG-II trial which is a prospective cohort study that thoroughly analyzed the changes of LV function in patients with HFrEF receiving wearable cardioverter-defibrillator (WCD) under optimization of medical therapy. For this substudy, RVFWS, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and 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. Study patients were divided into LV improvement and non-improvement groups, defined as an LV ejection fraction (LVEF) of >35% or <=35% at last available follow-up (long-term follow-up).
Results: The study included 260 patients (mean age 57 years, 68% men). The median follow-up was 31.5 months (IQR: 18.2-45.4). One hundred fifty-one (58%) patients experienced LV improvement in the long-term. No significant differences of RV function were observed at baseline assessment; 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 %, p <0.001, TAPSE 19.7 ± 5.1 vs. 17.4 ± 4.9 mm, p = 0.002, FAC 39.7 ± 8.5 vs. 35.2 ± 9.4 %, p <0.001). RVFWS was associated with LVEF at last follow-up (r = 0.26, p <0.001). RVFWS/PASP ratio identified the highest rate of RV-PA uncoupling (25.6%) in comparison to TAPSE/PASP (9%) and FAC/PASP (13.8%). While no differences in RV-PA coupling markers were observed between the groups at baseline, lower long-term LVEF was associated with worse RV-PA coupling at early follow-up (RVFWS/PASP (r = 0.331, p <0.001), TAPSE/PASP (r = 0.323, p <0.001), and FAC/PASP (r = 0.312, p <0.001). RVFWS/PASP identified RV-PA uncoupling was associated with a higher risk of all-cause mortality (hazard ratio 5.41, 95% confidence interval 1.20-24.34, p = 0.003).
Conclusion: In patients with newly diagnosed HFrEF, RV dysfunction observed during the early follow-up period suggests a lower potential for LV improvement in the long-term.