Objectives This study sought to investigate how right ventricular (RV) contractile function and its coupling with pulmonary circulation (PC) stratify clinical phenotypes and outcome in heart failure preserved ejection fraction (HFpEF) patients.

Background Pulmonary hypertension and RV dysfunction are key hemodynamic abnormalities in HFpEF.

Methods Three hundred eighty seven HFpEF patients (mean age 64 ± 12 years, 59% females, left ventricular ejection fraction 59 ± 7%) underwent RV and pulmonary hemodynamic evaluation by echocardiography (entire population) and right heart catheterization (219 patients). Patients were investigated by tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) relationship and stratified according to TAPSE/PASP ratio tertiles (1: <0.35; 2: 0.35 to 0.57; 3: >0.57). Specifically, TAPSE/PASP ratio was taken as a noninvasive index of RV to PC coupling based on the correlation with invasively evaluated RV systolic elastance/arterial elastance (r = 0.35; p < 0.0001).

Results Groups had similar prevalence of comorbidities except for a higher prevalence of atrial fibrillation and kidney dysfunction in tertile 1. Progressively increasing levels of natriuretic peptides, worse systemic and pulmonary hemodynamics, abnormal exercise aerobic capacity and ventilatory inefficiency were observed from the highest to lowest TAPSE/PASP tertile. TASPE/PASP correlated with pulmonary artery compliance (r = 0.69; p < 0.0001). Remarkably, the tertile 1 group distributed along the worse portion of the curve at lower pulmonary artery compliance and higher pulmonary vascular resistances. In addition, the TAPSE/PASP ratio emerged as an independent predictor of worse outcomes.

Conclusions A thorough assessment of RV-PC coupling and RV contractile function stratify HFpEF phenotypes at different level of risk. These observations shift the interest toward therapeutic strategies that may benefit the right heart as primary unmet need in the complex pathophysiology of the HFpEF syndrome.

目的本研究旨在探讨心力衰竭保留射血分数（HFpEF）患者的右心室（RV）收缩功能及其与肺循环（PC）的关系如何分层临床表型和预后。

背景肺动脉高压和RV功能障碍是HFpEF的关键血液动力学异常。

方法387例HFpEF患者（平均年龄64±12岁，女性59％，左心室射血分数59±7％）接受了RV和超声心动图（整个人群）和右心导管检查的肺血流动力学评估（219例）。通过三尖瓣环平面收缩期偏移（TAPSE）与肺动脉收缩压（PASP）的关系对患者进行调查，并根据TAPSE / PASP比值三分位数对患者进行分层（1：<0.35； 2：0.35至0.57； 3：> 0.57）。具体而言，将TAPSE / PASP比值作为与有创评估的RV收缩期弹性/动脉弹性的相关性作为RV与PC耦合的非侵入性指标（r = 0.35； p <0.0001）。

结果各组的合并症患病率相似，但三分位数1的房颤和肾功能障碍患病率较高，从最高到最低的TAPSE观察到钠尿肽水平逐渐升高，全身和肺血流动力学变差，运动有氧能力异常和通气效率低下/ PASP三分法。TASPE / PASP与肺动脉顺应性相关（r = 0.69； p <0.0001）。值得注意的是，在较低的肺动脉顺应性和较高的肺血管阻力下，三分位数1组沿曲线的最差部分分布。此外，TAPSE / PASP比值已成为不良结局的独立预测指标。

结论全面评估RV-PC偶联和RV收缩功能可将HFpEF表型分为不同的风险水平。这些发现将人们的兴趣转向了可能有益于右心脏的治疗策略，因为这是HFpEF综合征的复杂病理生理学中最主要的未满足需求。