HAEMODYNAMIC CLASSIFICATION OF PULMONARY EMBOLISM AND ITS LONG TERM PROGNOSTIC ROLE

Pulmonary embolism (PE) is a major cause of cardiovascular morbidity and mortality worldwide. Despite advances in diagnostic and therapeutic strategies, accurate long-term risk stratification remains challenging, particularly among patients surviving the acute phase of intermediate-high risk PE. While clinical scores, imaging findings, and laboratory biomarkers are routinely used for prognostic assessment, the role of invasive hemodynamic evaluation in predicting long-term outcomes has not been fully established. This study aimed to investigate the prognostic significance of invasive hemodynamic parameters obtained through right heart catheterization (RHC) in patients with intermediate-high risk acute PE and to evaluate their association with long-term all-cause mortality. Consecutive patients admitted to the Intensive Care Unit of the Cardiology Department of Modena University Hospital between January 2015 and December 2025 with confirmed intermediate-high risk PE were prospectively enrolled. All patients survived the acute event and underwent RHC before hospital discharge. Clinical, echocardiographic, and invasive hemodynamic variables were collected. Right ventricular dysfunction (RVD) was defined by a mean right atrial pressure ≥8 mmHg, pulmonary capillary wedge pressure <15 mmHg, and cardiac index <2.5 L/min/m². Long-term follow-up was performed until May 2026. Cox proportional hazards regression and Kaplan–Meier survival analyses were used to identify predictors of mortality. A total of 156 patients were included in the study. During a median follow-up of 65 months, 39 patients (25%) died. Several invasive hemodynamic and echocardiographic parameters were associated with mortality at univariable analysis. Multivariable analysis identified RVD, pulmonary artery pulsatility index (PAPi), and right ventricular stroke work index (RVSWI) as independent predictors of long-term mortality, with RVD representing the strongest determinant. Repeat RHC performed six months after the acute event demonstrated a dynamic evolution of right ventricular function: 57.1% of patients with baseline RVD showed functional recovery, whereas 47.1% of patients without initial RVD developed new dysfunction. Persistent RVD was observed in 89.7% of deceased patients compared with only 8.7% of survivors (p<0.0001). Furthermore, the addition of persistent RVD to the prognostic model significantly improved its predictive performance and identified a subgroup of patients at markedly increased risk of death. These findings demonstrate that invasive hemodynamic assessment provides valuable prognostic information beyond conventional risk stratification tools in patients surviving intermediate-high risk acute PE. In particular, RVD detected by RHC is strongly associated with long-term mortality, while persistent RVD at six months represents the most powerful predictor of adverse outcomes. Serial invasive hemodynamic evaluation may therefore contribute to improved risk stratification and facilitate the identification of patients who could benefit from closer surveillance and more intensive long-term management following acute pulmonary embolism.