Prognostic Impact of Hemodynamic Transitions in Pulmonary Artery Pulsatility Index and Compliance in Advanced Heart Failure: A Post-hoc Analysis of the ESCAPE Trial

Background: Advanced heart failure (HF) remains associated with poor outcomes despite contemporary therapies. Right ventricular (RV) dysfunction, a hallmark of advanced HF, is strongly influenced by afterload. We aimed to evaluate whether the combined assessment of the pulmonary artery pulsatility index (PAPi) and pulmonary arterial capacitance (PAC)-and their transitions during acute-phase therapy-provides prognostic stratification in patients with advanced HF. Methods: We conducted a post-hoc analysis of the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial, including 146 patients with complete hemodynamic data. A bootstrap-based grid search identified prognostic cutoffs: PAPi at 2.67 and PAC at 2.03. The optimal zone was defined as PAPi ≥2.67 and PAC ≥2.03, the suboptimal zone as PAPi <2.67 or PAC <2.03. Patients were categorized into four groups based on transitions between zones from baseline to the final assessment after acute-phase therapy. The primary endpoint was a composite of all-cause mortality, left ventricular assist device implantation, or heart transplantation within 6 months. Results: At baseline, 127 patients were in the suboptimal zone. Following acute-phase therapy, 33 transitioned to the optimal zone, while 94 remained suboptimal. Kaplan-Meier curves demonstrated significant stratification among groups. In Cox regression models using the suboptimal→suboptimal as reference, transition to the suboptimal→optimal was associated with improved prognosis (multivariable hazard ratio 0.300, 95% confidence interval 0.107-0.847, P=0.023). Conclusions: Transitions in PAPi and PAC during acute-phase therapy were associated with subsequent outcomes in advanced HF. Combined assessment of PAPi and PAC may provide a novel therapeutic target for risk stratification and management in this high-risk population.