Non-invasive right ventricular pressure-volume analysis via 3D echocardiography for disease profiling and clinical outcomes

Abstract Although pressure-volume (PV) analysis using conductance catheterization is the gold-standard method for assessing right ventricular (RV) contractility and ventriculo-arterial coupling (VAC), its invasive nature limits routine clinical application. In everyday practice, three-dimensional echocardiography (3DE) has become a widely used imaging modality, providing an effective tool for assessing RV volumes. However, volumetric measures such as ejection fraction are highly load-dependent. Recently, the reconstruction of RV pressure curves using Doppler-derived measure of RV peak systolic pressure has been validated, enabling a more comprehensive assessment. Accordingly, our aim was to develop and evaluate a 3DE-derived method for noninvasive PV analysis, to quantify gold-standard metrics of RV systolic performance and coupling, and to assess their prognostic value in a cohort of patients with various left-sided cardiac diseases. A total of 213 patients were enrolled from the RVENet database, including heart transplant recipients (HTX), patients with heart failure with reduced ejection fraction (HF), severe mitral regurgitation (MR), and severe aortic stenosis (AS), all of whom underwent 3DE. Using dedicated software, non-invasively derived pressure and 3DE-derived volume traces were concatenated to generate PV loops, enabling the measurement of contractility (end-systolic elastance, Ees), afterload (arterial elastance, Ea), VAC (Ees/Ea), and stroke work (SW). The endpoint was a composite of all-cause mortality and heart failure hospitalization, with a median follow-up of 39 months. Significant differences in RV hemodynamics were observed among the study groups. AS patients exhibited the highest Ees values (0.50±0.21 mmHg/ml), followed by MR patients (0.43±0.22 mmHg/ml), whereas both HF (0.33±0.12 mmHg/ml) and HTX patients (0.34±0.07 mmHg/ml) had lower contractility (ANOVA, p0.001). AS patients also had the highest Ea values (0.66±0.40 mmHg/ml), while HTX patients had the lowest afterload (0.41±0.13 mmHg/ml) (ANOVA, p0.001). Regarding VAC, MR patients exhibited the highest Ees/Ea values (0.99±0.24), whereas HF patients showed the lowest values (0.68±0.19), indicating uncoupling (ANOVA, p0.001). SW was higher in MR and AS patients, while both HF and HTX groups had comparably lower values. During follow-up, 49 patients (23%) met the composite endpoint. By univariable Cox regression analysis, both Ea (HR 2.51 95% CI 1.21–5.21; p0.05) and Ees/Ea (HR 0.25 95% CI 0.08–0.82; p0.05) were significant predictors of adverse outcomes. Non-invasive PV loop analysis enabled detailed quantification of RV systolic performance and VAC, revealing characteristic alterations across different left-sided cardiac diseases. Moreover, Ea and VAC were associated with adverse clinical outcomes, highlighting their potential prognostic value. Further studies are needed to confirm the clinical value of non-invasive PV analysis across cardiopulmonary disease states.