Prominent V Waves May Overstate Pulmonary Vascular Disease in HFpEF

Left atrial stiffening can produce prominent V waves that raise pulmonary artery pressure independently of pulmonary vascular disease. In a retrospective Circulation study, 1,069 patients with heart failure with preserved ejection fraction (HFpEF) and less than moderate resting mitral regurgitation underwent invasive exercise hemodynamic testing. Prominent V waves were defined as pulmonary artery wedge pressure (PAWP) V waves exceeding mean PAWP by at least 10 mm Hg.

Prominent V waves occurred in 225 patients (21%) and were associated with greater left atrial enlargement, lower reservoir strain, and more atrial fibrillation. Pulmonary artery systolic pressure was higher than in patients without prominent V waves (54±16 versus 38±12 mm Hg), despite similar end-diastolic PAWP–pulmonary artery pressure gradients. Among patients with prominent V waves, correcting transpulmonary pressure gradients for the V wave reduced the prevalence of combined pre- and postcapillary pulmonary hypertension from 60.2% to 29.3%.

Despite similar corrected pulmonary vascular resistance between groups, patients with prominent V waves had lower apparent pulmonary artery compliance, more severe right ventricular dysfunction, and greater risk of heart failure hospitalization or death (adjusted hazard ratio 2.09; 95% CI 1.53–2.86). The findings suggest that V-wave transmission contributes to right ventricular afterload and that ignoring it may overestimate pulmonary vascular disease. The retrospective design cannot establish causality; full-text methods and follow-up details were unavailable for this update.