Delayed referral to advanced heart failure centers is associated with established right ventricular dysfunction and severe functional impairment in HFrEF
D Kosevic, J Stefanovic Neskovic, J Miladinovic, B Milovanovic, U Radak, N Andjelkovic, S Borovic, M BojicAbstract
Background
Delayed referral of patients with heart failure with reduced ejection fraction (HFrEF) to advanced heart failure (HF) centers is common and may result in progression to right ventricular (RV) dysfunction, which substantially limits therapeutic options and worsens functional status.
Purpose
To explore the association between RV dysfunction, structural remodeling, and functional impairment in patients with advanced HFrEF, highlighting the potential importance of early referral to specialized HF centers before the development of overt RV failure.
Methods
We retrospectively analyzed 39 consecutive patients with advanced HFrEF referred to a tertiary HF center. RV function was assessed using echocardiographic parameters (tricuspid annular plane systolic excursion [TAPSE], fractional area change [FAC]) and RV end-diastolic volume quantified by cardiac magnetic resonance (CMR). Functional capacity was evaluated using cardiopulmonary exercise testing, including oxygen uptake efficiency slope (OUES). Associations between RV parameters and functional indices were analyzed.
Results
Patients with advanced biventricular disease at the time of referral, with markedly impaired RV systolic function (mean TAPSE 11.1 ± 3.8 mm; FAC 19.0 ± 5.6%) and significant RV dilatation on CMR (RV EDV 213 ± 61 mL) were admitted from regional hospitals to Heart Failure Center at Cardiovascular Institute Dedinje. Functional capacity was severely reduced at the time of admission (OUES 1.52 ± 0.56). RV dilatation was significantly associated with impaired cardiopulmonary efficiency, with larger RV volumes corresponding to lower OUES values (r = −0.37, p = 0.022). These findings suggest that substantial RV remodeling and functional deterioration are already present at the time of advanced HF referral.
Conclusion
Patients with HFrEF referred to advanced HF centers frequently present with established RV dysfunction and severe functional impairment. Earlier referral, prior to the development of significant RV remodeling, may preserve cardiopulmonary efficiency and broaden advanced therapeutic opportunities and decrease mortality.