VERICIGUAT EFFECT ON RIGHT VENTRICULAR TO PULMONARY ARTERY COUPLING: A CASE REPORT

Abstract Introduction In patients with pulmonary hypertension due to left heart disease (PH–LHD), optimizing treatment of the underlying condition is recommended. Vericiguat may be considered in patients who have had worsening heart failure (HF) even with guideline–directed medical therapy (GDMT), but despite its beneficial role on endothelial function, its effect on right ventricular to pulmonary artery coupling (RVAC) is not well known yet. Case report A 75–years–old male patient, with HF with reduced ejection fraction (HFrEF) and difficult uptitration of GDMT due to hypotension and renal function worsening, was referred to our HF unit. Transthoracic echocardiography confirmed severely reduced left ventricular (LV) EF, preserved RV longitudinal function but reduced radial function, third degree LV diastolic dysfunction with elevated estimated filling pressures, severe PH (confirmed by recently performed right heart catheterization which showed combined pre– and post– capillary PH) and absence of systemic venous congestion. The patient was in New York Heart Association (NYHA) class II, but he experienced worsening HF with three hospitalizations in the last year (the last one occurring two months before and requiring inotropes and endovenous diuretic therapy), so vericiguat was introduced and gradually up titrated to 5 mg/day. At 1 month follow–up, we observed a reduction in estimated pulmonary artery systolic pressure (PASP) and an increase in right ventricular free–wall longitudinal strain (RVFWLS, figure 1). Accordingly, all the echocardiographic RVAC parameters we derived improved (figure 2), and RV myocardial work (RVMW) indices showed reduction in wasted work and increase in work efficiency (figure 3). Discussion Among patients with HF, PH is highly prevalent and associated with worse outcome. Nevertheless, drugs approved for pulmonary arterial hypertension are currently not indicated for PH–LHD. Vericiguat can be considered in patients who have had worsening HF despite treatment with GDMT to reduce the risk of CV mortality or HF hospitalization, and in our patient, affected by severe PH–LHD, it determined benefit in terms of pulmonary artery pressures, RV function, RVAC and RV efficiency. Conclusion In our case, advanced echocardiographic RVAC parameters, including RVMW, offered insight into potential vericiguat effects on RV function and pulmonary circulation in the setting of worsening HF and PH–LHD.