Geert Kleinnibbelink

General Introduction and Outline of Thesis 27 1 In the second part of this thesis, the focus is on the impact of altered haemodynamics and exercise on the RV in patients with PH. In Chapter 6 , we performed a systematic review and meta-analysis to determine the independent prognostic value of RV global longitudinal strain for a combined endpoint of mortality and PH-related events or all- cause mortality in patients with pulmonary hypertension. In Chapter 7, we elaborated on previous observations from our group, as we have demonstrated that the strain-area loop is able to detect afterload changes in PH patients. To better understand this observation, we assessedwhether the strain-area loop is able to detect changes in preload andwhether these lead to comparable changes in the invasive pressure-area loop. Furthermore, we investigated whether the strain-area loop would be valuable in the follow-up of PH patients. In Chapter 8 , we examined the impact of Selexipag, a drug prescribed to lower pulmonary vascular resistance, on the RV strain-area loop in PAH patients and how these effects translate to clinical benefits (at group level and within individuals). In Chapter 9 , we compared 1-year mortality rates between patients with patients with primary PH who were prescribed cardiac rehabilitation or exercise programmes versus a propensity- matched control group of primary PHwithout prescription for CR or exercise programmes. In the third part of this thesis, in Chapter 10 , we will integrate findings of this thesis with insight from other studies and we will discuss potential future directions for research.