Incremental Utility of Right Ventricular Dysfunction in Patients With Myeloproliferative Neoplasm–Associated Pulmonary Hypertension

Published:October 03, 2019DOI:https://doi.org/10.1016/j.echo.2019.07.010

      Highlights

      • In 301 MPN patients, PH was seen in 56%.
      • RV dysfunction was threefold more common among PH patients.
      • PH was associated with impaired LV compliance.
      • All-cause mortality was 27%, encompassing a total of 80 deaths.
      • Both PH grade and RV dysfunction independently conferred increased mortality risk.

      Background

      Myeloproliferative neoplasm (MPN) has been associated with pulmonary hypertension (PH) on the basis of small observational studies, but the mechanism and clinical significance of PH in MPN are not well established. The aims of this study were to expand understanding of PH in a well-characterized MPN cohort via study of PH-related symptoms, mortality risk, and cardiac remodeling sequalae of PH using quantitative echocardiographic methods.

      Methods

      The population comprised a retrospective cohort of patients with MPN who underwent transthoracic echocardiography: Doppler-derived pulmonary arterial systolic pressure applied established cutoffs for PH (≥35 mm Hg) and advanced PH (≥50 mm Hg); right ventricular (RV) performance was assessed via conventional indices (tricuspid annular plane systolic excursion [TAPSE], S′) and global longitudinal strain. Symptoms and mortality were discerned via standardized review.

      Results

      Three hundred one patients were studied; 56% had echocardiography-demonstrated PH (20% advanced) paralleling a high prevalence (67%) among patients with invasively quantified PASP. PH was associated with adverse left ventricular (LV) remodeling indices, including increased myocardial mass and diastolic dysfunction (P ≤ .001 for all): LV mass and filling pressure (P < .01) were associated with PH independent of LV ejection fraction. RV dysfunction by strain and TAPSE and S′ increased in relation to PH (P ≤ .001) and was about threefold greater among patients with advanced PH compared with those without PH. Patients with RV dysfunction were more likely to report dyspnea, as were those with advanced PH (P < .05). During median follow-up of 2.2 years, all-cause mortality was 27%. PH grade (hazard ratio, 1.9; 95% CI, 1.1–3.0; P = .012) and TAPSE- and S′-demonstrated RV dysfunction (hazard ratio, 3.3; 95% CI, 1.3–8.2; P = .01) were independently associated with mortality; substitution of global longitudinal strain for TAPSE and S′ yielded similar associations of RV dysfunction with death (hazard ratio, 3.2; 95% CI, 1.5–6.7; P = .003) independent of PH.

      Conclusions

      PH is highly prevalent in patients with MPN and is linked to LV diastolic dysfunction; echocardiography-quantified RV dysfunction augments risk for mortality independent of PH.

      Keywords

      Abbreviations:

      GLS (Global longitudinal strain), HR (Hazard ratio), LV (Left ventricular), LVEF (Left ventricular ejection fraction), MPN (Myeloproliferative neoplasm), PASP (Pulmonary artery systolic pressure), PH (Pulmonary hypertension), RV (Right ventricular), TAPSE (Tricuspid annular plane systolic excursion)
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