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Background Right ventricular function as assessed by cardiac magnetic resonance (CMR) has utility in the monitoring of patients with pulmonary arterial hypertension. 1 Whether changes in right ventricular function have prognostic value in group 3 pulmonary hypertension is not known.Methods Consecutive patients from the ASPIRE registry with group 3 PH diagnosed between 2009 and 2023 were included. Patients underwent a comprehensive assessment at baseline including pulmonary function and shuttle walk testing, emPHasis10, CMR and right heart catheterisation. Follow up assessment was carried out with repeat CMR after initiation of treatment. Prognostic value was assessed using univariable then stepwise multivariable Cox regression analyses.Results Follow-up CMR after initiation of pulmonary vasodilator treatment was available in 112 patients, 59% female with a mean age 64 (SD 11) years; 45% had COPD/emphysema, 42% ILD, 12% CPFE, and 13% non-parenchymal restriction. There were 35 deaths with a median survival of 32 months. The baseline RVEF was 36.04% (SD 11.1) and mean DRVEF was 2.14%. Predictive variables from univariate analysis were incorporated into a multivariable model and refined. Age (HR 1.02, 95% CI 1.00–1.04 p=0.034), mean pulmonary artery wedge pressure (HR 0.94 95% CI 0.89–0.99 p=0.014), DRVEF (HR 0.98, 95% CI 0.96–0.99, p = 0.009), and TLCO (HR 0.77, 95%CI 0.64–0.93 p=0.008) were independently associated with survival.Conclusions Change in RVEF is a strong, independent predictor of mortality in group 3 PH. Further exploration of CMR parameters as a clinical outcome measure in group 3 PH is warranted.Reference Alabed S, Garg P, Alandejani F, Dwivedi K, Maiter A, Karunasaagarar K, Rajaram S, Hill C, Thomas S, Gossling R, Sharkey MJ, Salehi M, Wild JM, Watson L, Hameed A, Charalampopoulos A, Lu H, Rothman AMK, Thompson AAR, Elliot CA, Hamilton N, Johns CS, Armstrong I, Condliffe R, van der Geest RJ, Swift AJ, Kiely DG. Establishing minimally.