Escape from the Past: Improved Risk Stratification in Advanced Heart Failure using Novel Hemodynamic Parameters

ObjectivesWe sought to determine whether novel hemodynamic parameters provide added prognostic value in a real world heart failure population undergoing right heart catheterization (RHC) for consideration of advanced surgical therapies. BackgroundInvasive hemodynamics are fundamental in the assessment of patients with advanced heart failure. Early studies showed that right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP), were significantly associated with long term outcomes, but cardiac index (CI) was not. In recent years, there has been a number of novel hemodynamic parameters such as cardiac power output (CPO), pulmonary artery pulsatility index (PAPI), and aortic pulsatility index (API) however it remains unclear, in part due to variability in study population and design, which hemodynamic parameters are most prognostic in regard to long-term need for OHT or left ventricular assist device (LVAD). MethodsThis study is a retrospective review of patients from the PRognostic Evaluation During Invasive CaTheterization for Heart Failure (PREDICT-HF) registry. The demographics, laboratory variables, vital signs, hemodynamic variables and outcomes of patients who underwent RHC at one of the 9 member institutions were collected. The cumulative endpoint for this analysis was survival to OHT or LVAD, or death within 6 months of RHC. ResultsA total of 846 patients were included for the analysis, of which 176 (21%) met the primary endpoint. The majority of those within the primary outcome either underwent LVAD implant (n=76, 42%) or died (n=75, 42%). On multivariate analysis, a model incorporating the traditional hemodynamic variables, PCWP (OR 1.10, 10.4-1.15, p < 0.001) and CI (OR 0.86, 0.81-0.92, p<0.001) were shown to be predictive of adverse outcomes. In a separate multivariate model incorporating novel variables, CPO (OR 0.76, 0.71-0.83, p<0.001), API (OR 0.94, 0.91-0.96, P < 0.001) and PAPI (OR 1.02, 1.00-1.03, p 0.027) were all predictive. Moreover, patients with positively concordant API and CPO had the best freedom from endpoint (94.7%), whilst those with negatively concordant API and CPO had the worst freedom from endpoint (61.5%, p < 0.001). Those with discordant API and CPO had similar freedom from endpoint (high API and low CPO 83.7%; low API and high CPO 89.7%). ConclusionThe novel hemodynamic parameters of API and CPO are highly predictive of the need for OHT or LVAD or death within 6 months and in combination offer added prognostic value.