Prognostic Significance of the Right Ventricular to Left Ventricular Volume Ratio in Pulmonary Hypertension: A Multimodality Validation Study

Presenting Author(s)

• GF

  Giorgia Falco, MD

  MD, Fellow
  Weill Cornell Medicine, Presbyterian Hospital, New York

Primary Author(s)

• GF

  Giorgia Falco, MD

  MD, Fellow
  Weill Cornell Medicine, Presbyterian Hospital, New York

Co-Author(s)

• LJ

  Lily Jin, BSc

  Research Coordinator
  Weill Cornell Medicine
• RZ

  Robert S. Zhang, MD

  Instructor in Medicine
  Weill Cornell Medicine
• NR

  Nil Rawal, MD

  Resident
  Weill Cornell Medicine
• MR

  Mahniz Reza, BA

  Research Assistant
  Weill Cornell Medicine
• JL

  Jiahao Li, MSc

  PhD Candidate
  Weill Cornell Medicine
• PV

  Pablo Villar-Calle, MD

  Instructor in Medicine
  Weill Cornell Medicine
• ZF

  Zachary Falk, MD

  Cardiology Fellow
  NewYork-Presbyterian Hospital
• AT

  Annie Tsay, MD

  Fellow in Medicine
  NYP-Weill Cornell Medical Center
• AC

  Andre T. Cheng, MD

  Clinical Fellow
  Weill Cornell Medicine
• 

  Pascal Spincemaille, PhD

  Associate Professor of Physics Research In Radiology
  Weill Cornell Medicine
• 

  Jonathan W. Weinsaft, MD

  Chief of Cardiology, Professor of Medicine
  Weill Cornell Medicine
• 

  Jiwon Kim, MD

  Associate Professor of Medicine
  Weill Cornell Medicine

Background: RV end-diastolic volume indexed to body surface area (RVEDV Index) is commonly used to assess RV dilation; however, it may underestimate the severity of dilation in some cases. The RVEDV/LVEDV (RV/LV Volume ratio) is an emerging marker of adverse RV chamber remodeling, though its incremental prognostic value remains unknown.

Methods: The study population was comprised of patients with known or suspected pulmonary hypertension (PH) enrolled in a prospective CMR study. LV and RV volumes were quantified using planimetry from contiguous short-axis steady-state free precession (SSFP) cine-CMR images. In accordance with prior studies, RV/LV volume ratio ≥1.27, was used to define adverse RV remodeling. Clinical characteristics, follow-up data, and all-cause mortality were recorded blinded to imaging data. The primary outcome was a composite of all-cause mortality and heart failure hospitalization.

Results: Of the 321 patients enrolled in this prospective study (53% women, mean age 56 ± 15 years), 69 (21.5%) had an abnormal RV/LV ratio. Patients with an abnormal ratio were older (60.9 vs. 55.3 years, p = 0.006) and more likely to have New York Heart Association (NYHA) class ≥2 symptoms (66.2% vs. 37.3%, p < 0.001). Over a mean follow-up of 1.8 ± 1.3 years, 82 patients (25.5%) experienced the primary outcome. The abnormal RV/LV ratio group had a significantly higher rate of events (46.4% vs. 19.8%, p < 0.001). As shown in Table 1, an abnormal RV/LV ratio was associated with a greater than 3-fold increased risk of all-cause mortality and heart failure hospitalization (HR 3.28; 95% CI: 2.07–5.20, p < 0.001). In multivariable analysis (Table 2), after adjusting for age, sex, RVEDVi, RVEF, and RV global longitudinal strain (GLS), the RV/LV ratio remained a significant independent predictor of the primary outcome (HR 2.66; 95% CI: 1.54–4.59, p < 0.001). Kaplan-Meier analysis demonstrates increased risk of death and heart failure hospitalization among patients with abnormal RV/LV ratio (p< 0.001) (Figure 1).

Conclusion: RV/LV volume ratio is a robust, independent predictor of adverse clinical outcomes in patients with pulmonary hypertension. Its ease of measurement and independent prognostic value, as demonstrated in this study, support its potential for broader adoption in clinical practice.

Kaplan-Meier curve comparing the probability of event free survival in patients with abnormal RV/LV ratio