Mechanisms of Right Ventricular Adaptation in Patients With Heart Failure With Preserved Ejection Fraction

Study Overview
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Brief Summary
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Biventricular PV-loop studies and advanced imaging to assess left-to-right ventricular interaction in HFpEF: In a group of 30 HFpEF patients with clinical indication for LH/RH catheter investigation, we will perform biventricular PV loop assessment in combination with extensive imaging (MRI, echo) for in-depth analysis of left-to-right ventricular interaction in the different HFpEF categories, both under baseline and stress (volume challenge and exercise) conditions.

Detailed Description
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The right ventricle is the main determinant of prognosis in pulmonary hypertension . The response of the right ventricle to the structural alterations and increasing afterload in the pulmonary circulation is a complex process. The interplay between neuroendocrine and paracrine signalling and increased afterload may lead to myocardial ischemia and inflammation, resulting in loss of myocytes, myocardial fibrosis and RV-arterial uncoupling. Pulmonary hypertension in the setting of heart failure with preserved ejection fraction (HFpEF-PH) is a frequent complication which is associated with impaired prognosis. HFpEF-PH is defined by a high mean pulmonary artery pressure (> 20 mm Hg), high left ventricular end-diastolic pressure (LVEDP > 15 mm Hg) and a normal systolic left ventricular function with impaired diastolic function. However, not all HFpEF patients develop pulmonary vascular remodelling with a high transpulmonary pressure gradient, and increased pulmonary vascular resistance leading to adverse right ventricular remodelling. Ageing, increased left atrial pressure and stiffness, mitral regurgitation, as well as features of metabolic syndrome, including obesity, diabetes and hypertension, are recognized as clinical risk factors for HFpEF-PH. A main and emerging question in that context is the interplay between the right and left ventricle in HFpEF-PH, and whether diastolic left ventricular failure is the driving force of the hemodynamic and right ventricular functional changes. Recent studies have shown that HFpEF-PH patients demonstrate haemodynamic limitations during exercise, including impaired recruitment of LV preload due to excessive right heart congestion and blunted RV systolic reserve compared to HFpEF without PH . However, up to now, no data exist about the mechanism of interplay between RV, LV and pulmonary haemodynamics in HFpEF and HFpEF-PH. Whereas in patients with HFpEF, PV loop analysis has demonstrated that increased end-diastolic pressure at rest is associated with higher end-diastolic stiffness, and a consistently upwards and leftwards shifted pressure volume relationship during exercise and volume challenge, Gortner et al suggest that reduced LV preload (measured by LV transmural pressure gradient) due to excessive RV congestion, is a major driver for reduced cardiac output in HFpEF-PH. However, preliminary own data in 21 patients with HFpEF demonstrate a more complex relationship with approximately one third of patients not showing an increase of (RV and LV ) end-diastolic pressure volume relation during exercise. Thus, a simultaneous PV loop-catheterization of LV and RV, in addition to right heart catheter, would therefore provide an enormous gain of knowledge about the interaction of RV and LV and would contribute to a better understanding of the pathophysiology of HFpEF-PH and HFpEF.

Official Title
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Disclosing Mechanisms of Right Ventricular Adaptation in Patients With Heart Failure With Preserved Ejection Fraction With and Without Pulmonary Hypertension - Insights From Invasive Hemodynamic and Imaging

Conditions
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Heart Failure, Diastolic

Intervention / Treatment
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* Procedure: conductance catheter measurement


Participation Criteria
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Eligibility Criteria
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Inclusion criteria: Diagnosis of HFpEF as follows Heart failure NYHA II or NYHA III LVEF ≥ 50% HFA-PEFF score ≥ 5 OR HFA-PEFF score 2-4 with one of the following criteria: baseline PCWP ≥ 15 mm Hg OR PCWP increase ≥ 10 mm Hg with exercise ( 20 Watt) stable medical therapy for last 4 weeks Exclusion criteria: Significant coronary stenosis > 50% or valvular heart disease requiring intervention coronary or cardiac valvular intervention < 3 months uncontrolled rate of atrial fibrillation Severe chronic kidney disease (MDRD eGFR < 30 ml/min) Life expectancy < 12 months Contraindication to MRI or other planned investigations

Ages Eligible for Study
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Minimum Age: 50 Years
Maximum Age: 85 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Diagnostic
Intervention Model: Single Group Assignment
Interventional Model Description: single cohort observational pathophysiologic study
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: biventricular conductance catheter<br>patients with indication for invasive assessment receive right and left heart catheter and parallel biventricular conductance catheter at rest and stress | Procedure: conductance catheter measurement<br>* biventricular parallel conductance catheter measurement at rest and stress conditions, + CMR at rest and stress<br>* Other names: pressure volume loop catheter measurement;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| delta Eed | RV stiffness measured by conductance catheter is reduced alreday in early HFpEF stages | immediate after procedure | 
| delta RV volume | homeometric followed by teterometric adaptation with consecutive dilation of the RV occurs with disease progression from HFpEF-Non-PH ti ICC-PH_HFpEF to cpc-PH-HFpEFprogressive H, impacting position and motion of the septum with stress | immediate after procedure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| correlation of delta RV longitudinal strain with Eed | RV longitudinal strain (related to RV EDV) is the best predictor of RV diastolic stiffness (Eed) in HFpEF-PH (correlation analysis) | immediate after procedure | 
| delta transmural septal pressure | acute change of the transmural pressure gradients from rest to stress conditions, adversly impacts LV filling | immediate after procedure | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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HFpEF, pulmonary hypertension