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Background The pulmonary artery pulsatility index (PAPi) is a composite measure of right heart function, and low PAPi is associated with increased likelihood of mortality in patients hospitalized with cardiogenic shock. Our aim was to determine how PAPi correlates with other measures of right heart function and whether PAPi is associated with outcomes in ambulatory outpatients with advanced heart failure. Methods We assessed 673 consecutive ambulatory outpatients for heart transplantation over 10 years. The median age was 52 years, 72% were male, and dilated cardiomyopathy was the most common cause. All patients underwent detailed assessment, including right heart catheterization, and PAPi was calculated. The coprimary endpoints were death, urgent heart transplantation and mechanical circulatory support. Results Median PAPi was 2.2 (interquartile range 1.42–3.62), and variation was predominantly due to variation in right atrial pressure. PAPi was well correlated with the right atrial pressure to pulmonary capillary wedge pressure ratio (rho –0.766) but less well correlated with the right ventricular stroke work index (rho 0.561) and tricuspid annular plane systolic excursion (rho 0.292). Patients in the lowest PAPi quartile (0.16–1.41) had lower event-free survival at 1 year (68.7%) and 3 years (45.6%) compared with all other PAPi quartiles (log rank P = 0.0286). Conclusions PAPi offers a composite measure of right heart function that differs from other right heart catheter or echocardiographic measures. A PAPi of less than 1.41 is associated with adverse clinical outcomes in ambulatory outpatients with advanced heart failure.