Geert Kleinnibbelink

Chapter 11 226 Part ll – Altered haemodynamics and exercise in patients with pulmonary hypertension In Chapter 6 , we performed a systematic review and meta-analysis to examine whether RV longitudinal strain, i.e. a relatively novel measure of RV function, has prognostic value for future events in patients with PH. The key finding was that RV longitudinal strain has independent prognostic value for all-cause mortality. To a lesser extent, RV longitudinal strain also demonstrated independent predictive capacity for the combined endpoint of mortality and PH-related events. Taken together, these findings emphasize that RV longitudinal strain is a valuable tool with independent prognostic value for all-cause mortality in PH patients. In Chapter 7 , we compared the impact of preload manipulation on RV strain-area loop (another novel measure of RV function) versus pressure-area loop, and subsequently compared invasive and non-invasive assessment of cardiac contractility. We showed that a reduction in preload leads to a larger contribution of longitudinal myocardial strain to facilitate systolic volume ejection and vice versa . Following comparison of the RV strain- area and pressure-area loop, we found a strong correlation in the assessment of cardiac contractility. This suggests that the invasive and non-invasive loops provide comparable information, at least information related to identification of loop shifts and cardiac contractility. In Chapter 8 , we explored the impact of 17-weeks Selexipag on strain-area loop characteristics and, subsequently, relate these outcomes to changes in clinical status in patients with PAH. At group level, we found that treatment with Selexipag did not change any RV strain-area loop characteristics nor did treatment change other measures of RV function or any clinical outcomes. When, stratified to clinical outcome, we found that PH patients who improved their clinical status following Selexipag treatment showed an increase in RV longitudinal strain. In contrast, PH patients that showed no benefit of treatment revealed a decrease in RV longitudinal strain. These opposite changes in RV longitudinal strain between PH patients who clinically improved versus deteriorated may be coupled to successful decline or non-decline in pulmonary vascular resistance, respectively. These changes may, subsequently, explain the clinical (non-)response to Selexipag.