Hemodynamic transitions in pulmonary artery pulsatility index and compliance in advanced heart failure

• Advanced HF often has poor outcomes accompanied by RV dysfunction. • Suboptimal PAPi–PAC combinations were observed in the majority of acute-phase patients (87%). • Transition to the optimal PAPi–PAC zone during acute-phase treatment was associated with improved outcomes. • Integrated assessment of PAPi and PAC may provide a new framework for therapeutic evaluation and risk stratification in advanced HF. Advanced HF often has poor outcomes accompanied by RV dysfunction. Suboptimal PAPi–PAC combinations were observed in the majority of acute-phase patients (87%). Transition to the optimal PAPi–PAC zone during acute-phase treatment was associated with improved outcomes. Integrated assessment of PAPi and PAC may provide a new framework for therapeutic evaluation and risk stratification in advanced HF. Advanced heart failure (HF) remains associated with poor outcomes despite contemporary therapies, with right ventricular dysfunction influenced by afterload. This study evaluated whether combined assessment of the pulmonary artery pulsatility index (PAPi) and capacitance (PAC), and their transitions during acute-phase therapy, provides prognostic stratification in patients with advanced HF. This post-hoc analysis of the ESCAPE trial included 146 patients with complete hemodynamic data. A bootstrap-based grid search identified prognostic cutoffs: PAPi at 2.67 and PAC at 2.03 ( optimal , PAPi ≥2.67 and PAC ≥2.03; suboptimal , PAPi <2.67 or PAC <2.03). Patients were categorized based on transitions between zones from baseline to 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. The mean age was 56.2 years, 39 patients (26.9%) were female, and the median left ventricular ejection fraction was 20.0%. At baseline, 127 patients (87.0%) were suboptimal . Following acute-phase therapy, 33 (22.6%) transitioned to optimal , whereas 94 (64.4%) remained suboptimal . Kaplan–Meier curves demonstrated significant stratification among groups based on transitions (log-rank P = 0.016). In Cox regression models using the suboptimal→suboptimal group as reference, suboptimal→optimal transition was associated with improved prognosis (multivariable hazard ratio 0.300, 95% confidence interval 0.107–0.847, P = 0.023). 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 therapeutic target for risk stratification and management in this high-risk population.