Myocardial Mechanisms in Heart Failure With Preserved Ejection Fraction

Inclusion criteria

• HFpEF criteria
• Age ≥30 years.
• Left ventricular ejection fraction ≥50% measured by echocardiography, CMR or MUGA (measured within one year + clinical stability)
• Definition of HFpEF: signs and/or symptoms of HF, NYHA functional class II-IV, and at least one of the following:
• Elevated BNP (≥75 pg/ml in sinus rhythm or ≥225 pg/ml in atrial fibrillation/flutter) or NTproBNP (≥225 pg/ml in sinus rhythm or ≥675 in atrial fibrillation/flutter) at baseline. Choice of BNP or NTproBNP is based on availability at each clinical center.
• Prior HF hospitalization (primary reason for the hospitalization is HF with elevated natriuretic peptide levels \[using the thresholds listed above\], requiring IV diuresis for HF, or pulmonary edema or pulmonary vascular congestion on chest radiography).
• Previously documented elevated pulmonary capillary wedge pressure (PCWP) at rest (≥15 mmHg) or during exercise (≥25 mmHg for supine exercise or PCWP/cardiac output ratio ≥2 mmHg/L/min for upright exercise).
• Elevated H2FPEF score69 (≥5) or HFA-PEFF70 score (≥5).
• Suspected HFpEF criteria
• Age ≥30 years.
• Left ventricular ejection fraction ≥50% measured by echocardiography, CMR or MUGA (measured within one year + clinical stability)
• Signs and/or symptoms of HF, NYHA functional class II-IV and all of the following:
• Does not meet BNP or NT-proBNP criteria for HFpEF (above)
• No prior HF hospitalization meeting HF criteria (above)
• No previous hemodynamic catheterization documentation of HF (as above)

Exclusion criteria

• 1\. Inadequate echo or fluoroscopic images.
• \. Neck anatomy unfavorable for jugular venous cannulation
• \. Therapy with direct oral anticoagulants without cessation for a period (age, renal function, and agent specific) deemed adequate to normalize coagulation according to local clinical guidelines.
• \. Previous or ongoing therapy with warfarin with INR ≥ 1.6 measured day before or of EMB
• \. Platelet count \< 50,000/ml
• \. Active bleeding or coagulation disorder
• \. Infection or fever
• \. Endocarditis
• \. Pregnancy
• \. Intracardiac thrombus
• \. RV Aneurysm
• \. Clinically significant tricuspid, pulmonary or aortic valve stenosis
• \. Tricuspid or pulmonary mechanical valve prosthesis
• \. Left bundle branch block