Mechanisms of Right Ventricular Adaptation in Patients With Heart Failure With Preserved Ejection Fraction (INTERACT-HFpEF)

Disclosing Mechanisms of Right Ventricular Adaptation in Patients With Heart Failure With Preserved Ejection Fraction With and Without Pulmonary Hypertension - Insights From Invasive Hemodynamic and Imaging

Biventricular PV-loop studies and advanced imaging to assess left-to-right ventricular interaction in HFpEF: In a group of 30 HFpEF patients with clinical indication for LH/RH catheter investigation, we will perform biventricular PV loop assessment in combination with extensive imaging (MRI, echo) for in-depth analysis of left-to-right ventricular interaction in the different HFpEF categories, both under baseline and stress (volume challenge and exercise) conditions.

Study Overview

• Status: Unknown
• Conditions: Heart Failure, Diastolic
• Intervention / Treatment: Procedure: conductance catheter measurement

Detailed Description

The right ventricle is the main determinant of prognosis in pulmonary hypertension . The response of the right ventricle to the structural alterations and increasing afterload in the pulmonary circulation is a complex process. The interplay between neuroendocrine and paracrine signalling and increased afterload may lead to myocardial ischemia and inflammation, resulting in loss of myocytes, myocardial fibrosis and RV-arterial uncoupling. Pulmonary hypertension in the setting of heart failure with preserved ejection fraction (HFpEF-PH) is a frequent complication which is associated with impaired prognosis. HFpEF-PH is defined by a high mean pulmonary artery pressure (> 20 mm Hg), high left ventricular end-diastolic pressure (LVEDP > 15 mm Hg) and a normal systolic left ventricular function with impaired diastolic function. However, not all HFpEF patients develop pulmonary vascular remodelling with a high transpulmonary pressure gradient, and increased pulmonary vascular resistance leading to adverse right ventricular remodelling. Ageing, increased left atrial pressure and stiffness, mitral regurgitation, as well as features of metabolic syndrome, including obesity, diabetes and hypertension, are recognized as clinical risk factors for HFpEF-PH. A main and emerging question in that context is the interplay between the right and left ventricle in HFpEF-PH, and whether diastolic left ventricular failure is the driving force of the hemodynamic and right ventricular functional changes. Recent studies have shown that HFpEF-PH patients demonstrate haemodynamic limitations during exercise, including impaired recruitment of LV preload due to excessive right heart congestion and blunted RV systolic reserve compared to HFpEF without PH . However, up to now, no data exist about the mechanism of interplay between RV, LV and pulmonary haemodynamics in HFpEF and HFpEF-PH. Whereas in patients with HFpEF, PV loop analysis has demonstrated that increased end-diastolic pressure at rest is associated with higher end-diastolic stiffness, and a consistently upwards and leftwards shifted pressure volume relationship during exercise and volume challenge, Gortner et al suggest that reduced LV preload (measured by LV transmural pressure gradient) due to excessive RV congestion, is a major driver for reduced cardiac output in HFpEF-PH. However, preliminary own data in 21 patients with HFpEF demonstrate a more complex relationship with approximately one third of patients not showing an increase of (RV and LV ) end-diastolic pressure volume relation during exercise.

Thus, a simultaneous PV loop-catheterization of LV and RV, in addition to right heart catheter, would therefore provide an enormous gain of knowledge about the interaction of RV and LV and would contribute to a better understanding of the pathophysiology of HFpEF-PH and HFpEF.

• Study Type: Interventional
• Enrollment (Anticipated): 30
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Germany
  • Gießen, Germany, 35392
    • Recruiting
    • University Hospital Justus-Liebig University
    • Contact: Birgit Assmus, MD; Phone Number: 42637 +49 641 985; Email: birgit.assmus@innere.med.uni-giessen.de
    • Contact: Khodr Tello, MD; Phone Number: 56087 +49 641 985; Email: khodr.tello@innere.med.uni-giessen.de
  • Hessen
    • Frankfurt, Hessen, Germany, 60590
      • Recruiting
      • Goethe University Hospital
      • Contact: Eike Nagel, MD; Phone Number: 84491 +49696301; Email: eike.nagel@kgu.de
      • Contact: Valentina M Puntmann, MD; Phone Number: 84491 +49696301; Email: valentina.puntmann@kgu.de

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 50 years to 85 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion criteria:

Diagnosis of HFpEF as follows

• Heart failure NYHA II or NYHA III
• LVEF ≥ 50%
• HFA-PEFF score ≥ 5 OR HFA-PEFF score 2-4 with one of the following criteria:
• baseline PCWP ≥ 15 mm Hg OR PCWP increase ≥ 10 mm Hg with exercise (~20 Watt)
• stable medical therapy for last 4 weeks

Exclusion criteria:

• Significant coronary stenosis > 50% or valvular heart disease requiring intervention
• coronary or cardiac valvular intervention < 3 months
• uncontrolled rate of atrial fibrillation
• Severe chronic kidney disease (MDRD eGFR < 30 ml/min)
• Life expectancy < 12 months
• Contraindication to MRI or other planned investigations

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Diagnostic
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: biventricular conductance catheter; patients with indication for invasive assessment receive right and left heart catheter and parallel biventricular conductance catheter at rest and stress	Procedure: conductance catheter measurement; biventricular parallel conductance catheter measurement at rest and stress conditions, + CMR at rest and stress; Other Names: pressure volume loop catheter measurement

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
delta Eed	RV stiffness measured by conductance catheter is reduced alreday in early HFpEF stages	immediate after procedure
delta RV volume	homeometric followed by teterometric adaptation with consecutive dilation of the RV occurs with disease progression from HFpEF-Non-PH ti ICC-PH_HFpEF to cpc-PH-HFpEFprogressive H, impacting position and motion of the septum with stress	immediate after procedure

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
correlation of delta RV longitudinal strain with Eed	RV longitudinal strain (related to RV EDV) is the best predictor of RV diastolic stiffness (Eed) in HFpEF-PH (correlation analysis)	immediate after procedure
delta transmural septal pressure	acute change of the transmural pressure gradients from rest to stress conditions, adversly impacts LV filling	immediate after procedure

Collaborators and Investigators

• Sponsor: Johann Wolfgang Goethe University Hospital
• Collaborators: University of Giessen

Study record dates

Study Major Dates

• Study Start (Actual): February 15, 2020
• Primary Completion (Anticipated): December 1, 2021
• Study Completion (Anticipated): June 1, 2022

Study Registration Dates

• First Submitted: November 4, 2019
• First Submitted That Met QC Criteria: November 5, 2019
• First Posted (Actual): November 6, 2019

Study Record Updates

• Last Update Posted (Actual): July 28, 2020
• Last Update Submitted That Met QC Criteria: July 27, 2020
• Last Verified: July 1, 2020

More Information

Terms related to this study

• Keywords: pulmonary hypertension; HFpEF
• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Heart Failure; Heart Failure, Diastolic
• Other Study ID Numbers: Interact_HFpEF

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No