Insights into the Benefits of Reverse Remodeling from an Echocardiographic Pressure/Volume Loop Model in Patients With Heart Failure Treated With Sacubitril/Valsartan

Left ventricular (LV) reverse remodeling (RR) can occur in response to interventions that reduce the neurohormonal activation and hemodynamic overload in patients with heart failure with reduced ejection fraction (HFrEF). The aim of the study was to investigate whether the occurrence of LVRR in response to treatment with sacubitril/valsartan (S/V) is related to changes in ventricular-arterial (VA) coupling, as defined by the ratio of arterial elastance (Ea)/LV elastance (Ees), as well as to modifications of mechanoenergetic parameters. This multicenter study included 662 patients with HFrEF and LV EF ≤40% who underwent S/V therapy. The mean age of the study population was 65±11 years. Noninvasive pressure-volume (PV) loops were obtained from echocardiography with brachial artery blood pressure measurements. Ea, Ees and the ratio Ea/Ees and mechanoenergetic parameters, including stroke work (SW), potential energy (PE), PV area (PVA) and LV efficiency, were estimated. At a median interval of 7.8 months, 14% of patients exhibited LVRR, defined as an increase in LVEF >10% and a relative decrease in LV end-systolic volume >15%. In these patients, VA coupling changed from 2.90 ± 1.33 to 1.58 ± 0.53 (-45%) and LV efficiency increased from 46% to 57% (+24%), while PE decreased from 0.68 ± 0.18 joule to 0.44 ± 1.0 joule (-35%). VA coupling was closely associated with LV efficiency at baseline (r = -0.92) and after follow-up (r = -0.74). In conclusion, LVRR that occurred in patients treated with S/V was associated with a better VA coupling and likely accounted for the beneficial effects on LV efficiency, namely SW/PVA.