While in heart failure with reduced ejection fraction, left ventricular reverse remodeling is associated with better prognosis, right ventricular reverse remodeling (RVRR) was less investigated in pulmonary arterial hypertension (PAH).

To investigate whether RVVR assessed by echocardiography could help to stratify PAH patient's prognosis.

Between 2002 and 2019, consecutive PAH patients were included, treated and followed in a single PAH center in accordance with the guidelines. In addition to regular risk stratification parameters, we measured several RV systolic function and size parameters at baseline, 1-year of follow-up as well as their change (i.e., delta) under treatment. Primary composite outcome was 3-year transplant-free survival and death from all cause from the 1-year evaluation. Conditional inference trees were used to determine which echocardiographic parameters and cutoffs values were associated with primary outcome from hierarchy of multiple covariates in multivariable Cox regression analysis.

In total, 126 incident patients were included (63% female, mean age 59±18 yo), mainly due to connectivite-tissue disease and idiopathic PAH (26%, 22% respectively). At 1-y follow-up under PAH therapy, NYHA (P<0.01), NTproBNP (P<0.01), mPAP (P<0.01) were significantly improved. Conditional inference trees showed that 1-year tricuspid annular plane systolic excursion gain>1mm and right ventricular end-diastolic area decreased>2cm² were associated with 3-year transplant-free survival in multivariable Cox regression analysis (HR=0.23, 95% CI [0.08–0.61] P=0.0035, HR=0.34, 95% CI [0.12–0.94], P=0.038). Simple score from 0 (absence of RVRR), 1 (partial RVRR) and 2 (complete RVRR), describing the number of echocardiographic parameters reach at 1-year was investigated: complete RVRR depicted better prognosis (log-rank P<0.001) (Fig. 1).

Complete RVRR represent a new goal-oriented treatment strategy in PAH patients.