What does this research mean for the field?

Low LV stroke work and low LV external power are significant predictors of poor prognosis in pulmonary arterial hypertension, with LVSW HR 0.360 and LVEP HR 0.452. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

What question did this study set out to answer?

This research aims to evaluate the use of cardiac MRI-based left ventricular pressure volume loops to enhance prognosis in pulmonary arterial hypertension patients.

February 8, 2026

Cardiac MRI-based left ventricular pressure volume loops improve individualized evaluation of disease severity and prognosis in patients with pulmonary arterial hypertension

Key Result

In PAH patients, low LV stroke work (HR 0.360) and low LV external power (HR 0.452) predicted worse prognosis over 11.2 years, independent of age.

Key Points

This research aims to evaluate the use of cardiac MRI-based left ventricular pressure volume loops to enhance prognosis in pulmonary arterial hypertension patients.
Computed LV PV loops using CMR images and brachial arterial pressures
Divided PAH patients into groups based on RV pressure overload
Used invasive measurements from right heart catheterization
PAH patients had higher arterial elastance and ventriculo-arterial coupling but lower stroke work and efficiency compared to controls.
Higher arterial elastance and ventriculo-arterial coupling were linked to severe RV pressure overload.
Cox regression indicates low stroke work and low external power predict worse prognosis, associated with lower survival rates.

Structured PICO

Do CMR-based left ventricular pressure volume loops improve evaluation of disease severity and predict prognosis in patients with pulmonary arterial hypertension?

Population

60 patients with pulmonary arterial hypertension (PAH) (mean age 58.9 ± 17.2 years, 67% female) and 17 healthy controls (mean age 61.3 ± 5.3 years, 59% female).

Intervention

Non-invasive left ventricular pressure volume (PV) loops computed using cardiovascular magnetic resonance (CMR) images and brachial arterial pressures.

Comparator

Healthy controls, and within PAH patients (severe vs mild RV pressure overload based on ESC guidelines CMR risk factors).

Outcome

Occurrence of death or lung transplantation during follow-up.hard clinical

Non-invasive CMR-based left ventricular pressure-volume loops correlate with PAH severity and independently predict long-term lung transplantation-free survival.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Abstract Background In pulmonary arterial hypertension (PAH), increased pulmonary vascular resistance (PVR) leads to right ventricular (RV) pressure overload and left ventricular (LV) underfilling. (1) Novel non-invasive LV pressure volume (PV) loops computed using cardiovascular magnetic resonance (CMR) images and brachial arterial pressures provide estimates of LV stroke work (LVSW), LV efficiency (LVE), LV external power (LVEP), arterial elastance (Ea), and ventriculo-arterial coupling (VAC). (2) In this study, we aimed to investigate the use of CMR-based LV PV loops for a better individualized evaluation and prognostic prediction in PAH patients. Methods LV PV loops were computed using short axis balanced steady-state free-precession cine images. Invasive measurements were obtained from right heart catheterisation. (2, 3) Patients were divided into two groups to discriminate between patients with signs of severe RV pressure overload from patients with a mild RV pressure overload. This was done through a score created based on the CMR risk factors presented in the most recent guidelines for the diagnosis and treatment of pulmonary hypertension released by the European Society of Cardiology. (4) The major prognostic outcome was defined as the occurrence death or lung transplantation during follow-up. Results CMR scans from 60 PAH patients (age 58.9 ± 17.2 years, 67% female) and 17 healthy controls (age 61.3 ± 5.3 years, 59% female) were analyzed. PAH patients showed higher Ea and VAC but lower LVSW and LVE in comparison to controls. Within the PAH group, Ea and VAC were higher in severely pressure-overloaded patients, who also showed lower LVSW, lower LVE, and lower LVEP compared mildly pressure-overloaded patients (Figure 1). LVSW, LVE, Ea, and VAC correlated significantly with invasively measured mean pulmonary artery pressure and with PVR. LVEP correlated significantly with PVR (Figure 2a-d). After a median follow-up of 11.2 years (IQ range 8.7 – 13.3 years), 72% of PAH patients had died or undergone lung transplantation (n= 42/58, 2 patients lost at follow-up). Cox regression analysis showed that LVSW and LVEP are predictors of major outcome after adjusting for age with low LVSW or low LVEP values associated to worse prognosis (LVSW HR = 0.360, 95% CI = 0.140 – 0.929; LVEP HR 0.452, 95% CI = 0.207 – 0.987) (Figure 2e-f). Conclusions PAH patients show an impairment in LV mechanics which is dependent on the degree of RV pressure overload. Ea, VAC, LVSW, LVE, and LVEP correlate with the severity of PAH. High LVSW and LVEP are outcome predictors associated with longer lung transplantation-free survival.

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