BACKGROUND: Exercise right heart catheterization (RHC) unmasks different phenotypes based on hemodynamic response to exertion in patients with heart failure. The prognostic relevance of this approach in patients with heart failure and reduced ejection fraction (HFrEF) is uncertain.

METHODS: We analyzed 167 patients with HFrEF from the Kerckhoff-Klinik Heart Failure Registry who underwent supine exercise RHC with constant external workload between September 2009 and August 2014. The primary outcome was heart transplant/assist device free survival. Hemodynamic parameters that significantly predicted outcome were identified by multivariate Cox regression analysis and assessed further by Kaplan-Meier analysis after dichotomization using cutoffs derived from receiver operating characteristic analysis. Hemodynamic phenotypes were defined based on a dichotomized flow response (exercise-induced change in cardiac output [Delta CO]) combined with a dichotomized pressure response (exercise-induced change in systolic [Delta sPAP] or mean pulmonary arterial pressures).

RESULTS: Delta CO independently predicted transplant/assist device free survival (multivariate hazard ratio [HR] 1.67; 95% confidence interval [CI], 1.09-2.58; p = 0.02). Patients with Delta CO >= 1.15 liter/min had significantly better 5-year transplant/assist device free survival than patients with lower Delta CO (72.9% vs 22.5%; log-rank p < 0.001 [Kaplan-Meier analysis]). The hemodynamic phenotype of Delta CO <1.15 liter/min combined with Delta sPAP <17.5 mm Hg was associated with worse transplant/assist device free survival than Delta CO >= 1.15 liter/min combined with AsPAP >= 17.5 mm Hg (multivariate HR 7.39; 95% CI, 2.27-24.05; p = 0.001).

CONCLUSIONS: Exercise RHC parameters are important prognostic indices in HFrEF. Hemodynamic phenotyping using Delta CO and Delta sPAP allows enhanced risk stratification. (C) 2017 International Society for Heart and Lung Transplantation. All rights reserved.