Hemodynamic Profiles during Pulmonary Artery Pressure Sensor Implantation: Risk Stratification in Chronic HFrEF.

Background: Invasive hemodynamics may facilitate outpatient identification of ambulatory advanced HF. We analyzed cardiac failure risk stratified by four hemodynamic profiles recorded during implantation of the pulmonary artery pressure (PAP) sensor, CardioMEMS™ HF system.

Methods: This multicenter, retrospective cohort study included HFrEF patients who underwent PAP sensor implantation from 2015 to 2022. Hemodynamic profiles were categorized using the Stevenson HF classification, defining "cold" (impaired systemic perfusion) as cardiac index <2.2L/min/m2; and "wet" (hemodynamic congestion) as pulmonary capillary wedge pressure ≥18mmHg. The primary endpoint was 1-year cardiac failure, including all-cause mortality, inotrope dependence, need for durable VAD or heart transplantation.

Results: Among 512 patients (median age 71 years, 28% female, 77% NYHA class III, median NT-proBNP 2554 pg/mL), the hemodynamic profiles were as follows: 30% Warm-Dry, 22% Warm-Wet, 21% Cold-Dry, and 27% Cold-Wet. Overall, 118 patients (23%) experienced cardiac failure, of which 57 required chronic inotrope, durable VAD implantation, or heart transplantation and 61 died with medical therapy. One-year event-free survival differed across the profiles: Warm-Dry (90%), Warm-Wet (74%), Cold-Dry (80%), and Cold-Wet (61%) (P<0.001). Multivariable analysis (reference: Warm-Dry) showed increased cardiac failure risk in Cold-Wet (adjusted HR [95%CI]: 4.4 [2.4-7.8], P<0.001), Cold-Dry (adjusted HR [95%CI]: 2.2 [1.1-4.2], P=0.019), and Warm-Wet (adjusted HR [95%CI]: 2.8 [1.5-5.4], P=0.001).

Conclusion: At time of PAP sensor placement, an abnormal hemodynamic profile - especially Cold-Wet - was associated with increased cardiac failure risk, indicating subgroups who might have already progressed to ambulatory advanced heart failure.