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Background Among patients with heart failure and a preserved left ventricular ejection fraction (HFpEF), a distinct hemodynamic phenotype has been recently described, with potential clinical implication, i.e. latent pulmonary vascular disease (PVD). HFpEF patients with latent PVD have been shown to have worse outcome after creation of an interatrial septal shunt. However, the pathophysiological significance of latent PVD in HFpEF has not been thoroughly investigated. Methods We retrospectively analyzed our cohort of consecutive patients with HFpEF who have undergone a right heart catheterization at rest and during exercise between 2016 and 2020. HFpEF was defined based on a resting and/or exercise hemodynamics: pulmonary artery wedge pressure (PAWP) > 15 mmHg at rest; PAWP during exercise >= 25 mmHg; PAWP/cardiac output (CO) slope > 2 mmHg/L/min. Latent PVD was defined based on exercise pulmonary vascular resistance (PVR) > 1.74 WU. Results Out of 199 exercise right heart catheterization, 86 patients had a hemodynamic diagnosis of HFpEF. Of these, 68 (79%) qualified as HFpEF without PVD (HFpEF-PVR-) and 16 (21%) qualified as latent PVD (HFpEF-PVR+). HFpEF-PVR+ were older, presented more frequently with diabetes mellitus or glucose intolerance, had higher H2FPEF and HFA-PEFF scores, slightly lower LVEF, had more frequently a history of atrial fibrillation and had more frequently at tricuspid regurgitation ≥ moderate (p 2 WU) also at rest (72% vs 10%, p Conclusions HFpEF-PVR+ is associated with peculiar clinical and hemodynamic characteristics, reflecting a more advanced and polycomorbid HFpEF profile, characterized by heightened pulmonary vascular reactivity and overt cardiac limitation to exercise.

Background Both secondary tricuspid regurgitation (STR) and heart failure with preserved ejection fraction (HFpEF) are relevant public health problem in the elderly population, presenting with potential overlaps and sharing similar risk factors. However, the impact of severe STR on hemodynamics and cardiorespiratory adaptation to exercise in HFpEF remains to be clarified. Aim To explore the impact of severe STR on exercise hemodynamics and cardiorespiratory adaptation in HFpEF. Methods We analyzed invasive hemodynamics and gas-exchange data obtained at rest and during exercise from HFpEF patients with severe STR (HFpEF-STR), compared with 1:1 age, sex and body mass index matched HFpEF patients with mild or no STR (HFpEF-controls). Results 13 HFpEF-STR (mean age 72 years, 85% females, BMI 28 Kg/m2) and 13 age-, sex-, and BMI-matched HFpEF-controls patients were included. HFpEF-STR had higher (p Conclusions Severe STR complicating HFpEF impairs SV and CO reserve, leading to pulmonary vascular de-recruitment and relative left heart underfilling, mining the typical HFpEF pathophysiology. Exercise pathophysiology of secondary tricuspid regurgitation (STR) in heart failure with preserved ejection fraction (HFpEF).

Aims Exercise right heart catheterization (RHC) is considered the gold-standard test to diagnose heart failure with preserved ejection fraction (HFpEF). However, exercise RHC is an insufficiently standardized technique, and current haemodynamic thresholds to define HFpEF are not universally accepted. We sought to describe the exercise haemodynamics profile of HFpEF cohorts reported in literature, as compared with control subjects. Methods and results We performed a systematic literature review until December 2020. Studies reporting pulmonary artery wedge pressure (PAWP) at rest and peak exercise were extracted. Summary estimates of all haemodynamic variables were evaluated, stratified according to body position (supine/upright exercise), and the PAWP/cardiac output (CO) slope during exercise was extrapolated. Twenty-eight studies were identified, providing data for 2230 HFpEF patients and 706 controls. At peak exercise, patients with HFpEF achieved higher PAWP [30 (29–31) vs. 16 (15–17) mmHg, P Conclusions The haemodynamic profile of HFpEF patients is consistent across studies and characterized by a higher left and right filling pressure at rest, magnified by physical exercise. Our analysis strongly suggests that PAWP/CO slope might allow for a more consistent identification of HFpEF, irrespective of body position. This variable likely overcomes the shortcomings of an isolated peak PAWP measurement, allowing for a more univocal identification of HFpEF in patients with unexplained dyspnoea.

Aims Long scanning times impede cardiac magnetic resonance (CMR) clinical uptake. A ‘one-size-fits-all’ shortened, focused protocol [e.g. only function and late-gadolinium enhancement (LGE)] reduces scanning time and costs, but provide less information. We developed two question-driven CMR and stress-CMR protocols, including tailored advanced tissue characterization, and tested their effectiveness in reducing scanning time while retaining the diagnostic performances of standard protocols. Methods and results Eighty-three consecutive patients with cardiomyopathy or ischaemic heart disease underwent the tailored CMR. Each scan consisted of standard cines, LGE imaging, native T1-mapping, and extracellular volume. Fat/oedema modules, right ventricle cine, and in-line quantitative perfusion mapping were performed as clinically required. Workflow was optimized to avoid gaps. See Figure 1 for protocol details. Time target was 30% (CMR: from 42 ± 8 to 28 ± 6min; stress-CMR: from 50 ± 10 to 34 ± 6min, both P 45% of cases. Quality grading was similar between the two protocols. Tailored protocols did not require additional staff. Conclusions Tailored CMR and stress-CMR protocols including advanced tissue characterization are accurate and time-effective for cardiomyopathies and ischaemic heart disease.