Right ventricular reverse remodeling assessed by echocardiography as a new goal-oriented treatment strategy in PAH patients

Background While in heart failure with reduced ejection fraction, left ventricular reverse remodeling assessed by transthoracic echocardiography (TTE) is associated with better prognosis, right ventricular reverse remodeling (RVRR) was less investigated in pulmonary arterial hypertension (PAH) Purpose We aimed to investigate whether RVVR assessed by echocardiography could help to stratify PAH patient's prognosis. Methods Between 2002 and 2019, all consecutive PAH patients were included, treated and followed in a single PAH center in accordance with the current ESC/ERS guidelines. In addition to regular risk stratification parameters, we measured several echocardiographic RV systolic function and size parameters, including tricuspid annular plane systolic excursion (TAPSE, mm) or RV-end diastolic area (cm2) from apical-4 chamber view both at baseline, 1-year of follow-up as well as their change. Primary composite outcome was three-year transplant-free survival and death from all cause from the 1-year evaluation. Conditional inference trees were used to determine which TTE parameters and cutoffs values were associated with primary outcome from hierarchy of multiple covariates in multivariable Cox regression analysis. Kaplan-Meier curves were then drawn and compared with log-rank test. Results 126 incident PAH patients were included (63% female, mean age 59±18 yo), mainly due to connectivite-tissue disease and idiopathic PAH (26% and 22% respectively). At baseline, mean pulmonary arterial pressure was 42 (33, 52) mmHg. At 1-y follow-up under pulmonary vasodilation therapy, NYHA (p1 mm and 1-year RV end-diastolic area decreased >2 cm2 were associated with 3-year transplant-free survival in multivariable Cox regression analysis (HR=0.23, 95% CI [0.08–0.61] p=0,0035, HR=0.34, 95% CI [0.12–0.94], p=0.038). Simple score from 0 (absence of RVRR), 1 (partial RVRR) and 2 (complete RVRR), describing the number of TTE parameters reach at 1-year was then investigated. Patients with complete RVRR depicted better transplant-free survival than partial or absence of RVRR, log-rank p Conclusion Complete reverse remodeling from right ventricular size and function could represent a new goal-oriented treatment strategy in PAH patients. Funding Acknowledgement Type of funding sources: None. RVRR survival curves