Prominent V Waves Augment Right Ventricular Afterload Independent of the Lung Vessels in Heart Failure: Implications for Clinical Assessment of Pulmonary Vascular Disease

Chaikijurajai, T; Reddy, YNV; Harada, T; Naser, JA; Kazui, S; Akashi, N; Okuno, T; Ghanbari, F; Borlaug, BA

doi:10.1161/circulationaha.126.081799

Heart failure & cardiomyopathies

Prominent V Waves Augment Right Ventricular Afterload Independent of the Lung Vessels in Heart Failure: Implications for Clinical Assessment of Pulmonary Vascular Disease

CirculationPublished 11 Oct 2026retrospective cohort study

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Authors' conclusion

More than 1 in 5 patients with heart failure with preserved ejection fraction display prominent V waves in excess of end-diastolic PAWP. This augments right ventricular afterload due to backward transmission of the V wave, contributing to right heart failure that is independent of the pulmonary vasculature. Failure to account for the V wave during hemodynamic assessment overestimates the severity of pulmonary vascular disease present.

Study context

Population: Patients with heart failure with preserved ejection fraction and less than moderate mitral regurgitation at rest who underwent invasive hemodynamic exercise testing
Participants: 225 vs 844

Exposure: Patients with versus without prominent V waves
Prominent V wavesn = 225
Without prominent V wavesn = 844reference
Outcome: Left atrial (LA) volume index

Main finding

As reported in the abstract

Prominent V waves42.2± 15.0 · mL/m²

Without prominent V waves32.5± 13.0 · mL/m²

P < 0.001

Observational data: associations, not effects.

Further findings

LA reservoir strain

P < 0.001

Prominent V waves16.4 ± 7.5% %

Without prominent V waves23.2 ± 8.3% %

Atrial fibrillation

P < 0.001

Prominent V waves61.3%

Without prominent V waves22.9%

Operant LA reservoir stiffness

P < 0.001

Prominent V waves0.59 ± 0.25 mm Hg/mL

Without prominent V waves0.23 ± 0.24 mm Hg/mL

PA systolic pressure

P < 0.001

Prominent V waves54 ± 16 mm Hg

Without prominent V waves38 ± 12 mm Hg

End-diastolic PAWP-PA pressure gradient

P = 0.950

Prominent V waves3 ± 5 mm Hg

Without prominent V waves3 ± 4 mm Hg

Apparent PA compliance · similar corrected pulmonary vascular resistances

P < 0.001

Prominent V waves3.03 ± 1.56 mL/mm Hg

Without prominent V waves4.90 ± 2.27 mL/mm Hg

Outcome	← Lower with prominent V waves ←→ Higher with prominent V waves →	Adjusted hazard ratio (95% CI)	P value
Hospitalization for heart failure or death	0.20.5125	2.09 (1.53–2.86)	P < 0.001
	0.20.5125Adjusted hazard ratio (log scale)

Correlation with directly measured PA wedge pressure (PAWP) pressure-time integral

V wave-corrected PAWP: R 2 =0.96
mid-A wave PAWP: R 2 =0.86

P <0.001 for comparison

Combined pre- and postcapillary pulmonary hypertension in patients with prominent V waves

Before V wave correction: 60.2%
After V wave correction: 29.3%

Original publication

Prominent V Waves Augment Right Ventricular Afterload Independent of the Lung Vessels in Heart Failure: Implications for Clinical Assessment of Pulmonary Vascular Disease. Circulation. Published 11 October 2026. doi:10.1161/circulationaha.126.081799

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