Interventricular systolic asynchrony predicts prognosis in patients with systemic sclerosis-associated pulmonary arterial hypertension

Mortality and prognostic factors in connective tissue disease-associated pulmonary arterial hypertension patients complicated with right heart failure

OBJECTIVE

To identify predictive factors associated with mortality in connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) patients who were complicated with right heart failure (RHF).

METHODS

In this single-center retrospective study, baseline demographics, clinical features, laboratory results, and hemodynamic assessments were collected. Kaplan-Meier analysis was applied to analyze all-cause mortality. Univariate and forward stepwise multivariate Cox proportional regression analyses were performed to identify independent predictors of mortality.

RESULTS

A total of 51 right heart catheterization-confirmed CTD-PAH patients complicated with RHF were consecutively enrolled in this study from 2012 to 2022. Forty-eight (94%) enrolled patients were female and the mean age was 36.0 ± 11.8 years. Thirty-two (61.5%) were systemic lupus erythematosus-PAH and 33%/67% showed World Health Organization functional class III/IV, respectively. Twenty-five (49%) of those patients died and Kaplan-Meier analysis showed the overall 1-, 3-, and 5-week survival rates from the time of hospitalization as 86.28%, 60.78%, and 56.86%, respectively. RHF in CTD-PAH patients mainly resulted from progression of PAH (n = 19) and infection (n = 5), which also contributed to the leading causes of death. Statistical analysis between survivors and non-survivors showed that death from RHF was associated with higher levels of urea (9.66 vs 6.34 mmol/L, P = 0.002), lactate (cLac: 2.65 vs 1.9 mmol/L, P = 0.006), total bilirubin (23.1 vs 16.9 μmol/L, P = 0.018) and direct bilirubin (10.5 vs 6.5 μmol/L, P = 0.004), but with lower levels of hematocrit (33.7 vs 39, P = 0.004), cNa+ (131 vs 136 mmol/L, P = 0.003). Univariate and forward stepwise multivariate Cox proportional regression analyses indicated that the level of cLac (hazards ratio:1.297; 95% CI: 1.076-1.564; P = 0.006) was an independent risk factor for mortality.

CONCLUSION

The short-term prognosis of CTD-PAH complicated with RHF was very poor, and hyperlactic acidemia (cLac > 2.85 mmoL/L) was an independent predicting factor for mortality of CTD-PAH patients complicated with RHF.

Impact on right ventricular performance in patients undergoing permanent pacemaker implantation: Left bundle branch pacing versus right ventricular septum pacing

BACKGROUND

The novel method of left bundle branch pacing (LBBP) has been reported to achieve better electrical and mechanical synchrony in the left ventricle than conventional right ventricular pacing (RVP). However, its effects on right ventricle (RV) performance are still unknown.

METHODS

Consecutive patients undergoing dual-chamber pacemaker (PM) implantation for sick sinus syndrome (SSS) with normal cardiac function and a narrow QRS complex were recruited for the study. The pacing characteristics and echocardiogram parameters were measured to evaluate RV function, interventricular and RV synchrony, and were compared between ventricular pacing-on and native-conduction modes.

RESULTS

A total of 84 patients diagnosed with SSS and an indication for pacing therapy were enrolled. Forty-two patients (50%; mean age 65.50 ± 9.30 years; 35% male) underwent successful LBBP and 42 patients (50%; mean age 69.26 ± 10.08 years; 33% male) RVSP, respectively. Baseline characteristics were similar between the two groups. We found no significant differences in RV function [RV-FAC (Fractional Area Change)%, 47.13 ± 5.69 versus 48.60 ± 5.83, p = .069; Endo-GLS (Global Longitudinal Strain)%, -28.88 ± 4.94 versus -29.82 ± 5.35, p = .114; Myo-GLS%, -25.72 ± 4.75 versus -25.72 ± 5.21, p = .559; Free Wall St%, 27.40 ± 8.03 versus -28.71 ± 7.34, p = .304] between the native-conduction and LBBP capture modes, while the RVSP capture mode was associated with a significant reduction in the above parameters compared with the native-conduction mode (p < .0001). The interventricular synchrony in the LBBP group was also superior to the RVSP group significantly.

CONCLUSION

LBBP is a pacing technique that seems to associate with a positive and protective impact on RV performance.

Right Ventricle to Pulmonary Artery Coupling Predicts the Risk Stratification in Patients With Systemic Sclerosis-Associated Pulmonary Arterial Hypertension

Background

Pulmonary arterial hypertension (PAH) is a serious complication of systemic sclerosis (SSc). PAH has high mortality, and risk assessment is critical for proper management. Whether the right ventricle to pulmonary artery (RV-PA) coupling accurately assesses risk status and predicts prognosis in patients with SSc-associated PAH has not been investigated.

Methods

Between March 2010 and July 2018, 60 consecutive patients with SSc-associated PAH diagnosed by right heart catheterization were enrolled prospectively, and the mean follow-up period was 52.9 ± 27.0 months. The RV-PA coupling was assessed by the ratio of tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) which was obtained by transthoracic echocardiography. The simplified risk stratification strategy was applied to assess the risk level of participants, and the endpoint was a composite of all-cause death and clinical worsening.

Results

The receiver operating characteristic (ROC) curve of the ability to determine high-risk patients identified the optimal cut-off value of the TAPSE/PASP ratio as 0.194 mm/mmHg, and the ratio appeared to be a reliable indicator in the stratification of patients with high risk (area under the curve = 0.878, ROC P-value = 0.003), which showed the highest positive likelihood ratio (LR) (5.4) and the lowest negative LR (0) among a series of echocardiographic parameters. The TAPSE/PASP ratio was an independent predictive factor (HR = 0.01, 95% CI: 0.00–0.77, P = 0.037) for the composite endpoint, and patients with a TAPSE/PASP ratio >0.194 had a better overall survival for both the composite endpoint (log-rank χ² = 5.961, P = 0.015) and all-cause mortality (log-rank χ² = 8.004, P = 0.005) compared to the patients with a TAPSE/PASP ≤ 0.194.

Conclusion

RV-PA coupling assessed by the TAPSE/PASP ratio provides added value as a straightforward and non-invasive approach for predicting risk stratification of patients with SSc-associated PAH. Meanwhile, a lower TAPSE/PASP ratio identified a subgroup with worse prognosis.