Ventricle-pulmonary Artery Coupling Research Articles

Impact of right ventricle-pulmonary artery coupling in patients undergoing transcatheter aortic valve implantation

Right ventricle-pulmonary artery (RV-PA) coupling has been linked to clinical outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter valve implantation (TAVI). However, the best timing for prognostic assessment remains uncertain. Our aim was to determine the impact of RV longitudinal function parameters and RV-PA coupling on mortality in patients undergoing TAVI. Retrospective, single center, analysis including patients with AS who underwent TAVI between 2007 and 2021. Echocardiographic evaluation was performed before, shortly after the procedure, and during follow-up. RV-PA uncoupling was defined as a TAPSE/PASP ratio<0.55 (severe RV uncoupling was defined as TAPSE/PASP ratio<0.32. The effect of RV parameters on all-cause mortality up to 12 months was assessed. Among the 577 patients included, pre-procedural TAPSE/PASP ratio data were available for 205. RV-PA uncoupling was present in 113 patients (55.1%), with severe uncoupling observed in 31 (15.1%). Within the first 12 months after TAVI, 51 patients (9%) died. Severe RV-PA uncoupling was associated with mortality in univariable Cox regression; however, this association was lost after adjusting for EuroSCORE II. A significant association was found between the TAPSE/PASP ratio (per 0.1-unit increase) after the procedure and the primary endpoint (HR: 0.73; 95% CI: 0.56, 0.97; p=0.029). Higher postprocedural PASP (HR: 1.04; 95% CI: 1.02, 1.06; p<0.001 was also associated with all-cause mortality. V-PA uncoupling and PASP after TAVI are associated with all-cause mortality in patients and may be valuable for patient selection and for planning post-procedural care.

Early Alteration of Right Ventricle-Pulmonary Artery Coupling in Experimental Heart Failure With Preserved Ejection Fraction.

Pulmonary hypertension and right ventricular (RV) dysfunction are major prognostic determinants in patients with heart failure with preserved ejection fraction (HFpEF). The underlying pathomechanisms remain unknown. In this context, we sought to study the pathogenesis of pulmonary hypertension and RV dysfunction in a rat model of obesity-associated HFpEF. HFpEF was induced in obesity-prone rats fed a high-fat diet (n=13) and compared with obesity-resistant rats fed with standard chow (n=9). After 12 months, the animals underwent echocardiographic and hemodynamic evaluation followed by tissue sampling for pathobiological assessment. HFpEF rats presented mild RV pressure overload (with increased RV systolic pressure and pulmonary vascular resistance). No changes in pulmonary artery medial thickness and exvivo vasoreactivity (to acetylcholine and endothelin-1) were observed and RNA sequencing analysis failed to identify gene clustering in HFpEF lungs. However, released nitric oxide levels were decreased in HFpEF pulmonary artery, while lung expression of preproendothelin-1 was increased. In HFpEF rats, RV structure and function were altered, with RV enlargement, decreased RV fractional area change and free wall longitudinal fractional shortening, together with altered right ventricle-pulmonary artery coupling (estimated by tricuspid annular plane systolic excursion/systolic pulmonary artery pressure). Hypertrophy and apoptosis (evaluated by transferase biotin- dUTP nick-end labeling staining) were increased in right and left ventricles of HFpEF rats. There was an inverse correlation between tricuspid annular plane systolic excursion/systolic pulmonary artery pressure and RV apoptotic rate. Plasma levels of soluble suppression of tumorigenicity-2, interleukin-1β, -6 and -17A were increased in HFpEF rats. Obesity-associated HFpEF in rats spontaneously evolves to pulmonary hypertension-HFpEF associated with impaired right ventricle-pulmonary artery coupling that appears disproportionate to a slight increase in RV afterload.

Recent advances in multimodal imaging in tetralogy of fallot and double outlet right ventricle.

In the ever-evolving field of medical imaging, this review highlights significant advancements in preoperative and postoperative imaging for Tetralogy of Fallot (TOF) and double outlet right ventricle (DORV) over the past 18 months. This review showcases innovations in echocardiography such as 3D speckle tracking echocardiography (3DSTE) for assessing right ventricle-pulmonary artery coupling (RVPAC) and Doppler velocity reconstruction (DoVeR) for intracardiac flow fields evaluation. Furthermore, advances in assessment of cardiovascular anatomy using computed tomography (CT) improve the integration of imaging in ablation procedures. Additionally, the inclusion of cardiac magnetic resonance (CMR) parameters as risk score predictors for morbidity, and mortality and for timing of pulmonary valve replacement (PVR) indicates its significance in clinical management. The utilization of 4D flow techniques for postoperative hemodynamic assessment promises new insights into pressure mapping. Lastly, emerging technologies such as 3D printing and 3D virtual reality are expected to improve image quality and surgical confidence in preoperative planning. Developments in multimodality imaging in TOF and DORV are poised to shape the future of clinical practice in this field.

Right Ventricle-Pulmonary Artery Coupling in Patients Undergoing Cardiac Interventions.

This review aims to summarize the fundamentals of RV-PA coupling, its non-invasive means of measurement, and contemporary understanding of RV-PA coupling in cardiac surgery, cardiac interventions, and congenital heart disease. The need for more accessible clinical means of evaluation of RV-PA coupling has driven researchers to investigate surrogates using cardiac MRI, echocardiography, and right-sided pressure measurements in patients undergoing cardiac surgery/interventions, as well as patients with congenital heart disease. Recent research has aimed to validate these alternative means against the gold standard, as well as establish cut-off values predictive of morbidity and/or mortality. This emerging evidence lays the groundwork for identifying appropriate RV-PA coupling surrogates and integrating them into perioperative clinical practice.

Prognostic Role of RVGLS/PASP Ratio, a New Echocardiographic Parameter of the Right Ventricle-Pulmonary Artery Coupling, in Patients With Acute Heart Failure.

Few studies have addressed the predictive implications of right ventricular (RV) and pulmonary arterial (PA) coupling as assessed by echocardiography in patients with acute heart failure (AHF). This study aimed to ascertain the prognostic importance of RV-PA coupling in AHF cases and discern any divergence in its prognostic efficacy based on different heart failure (HF) phenotypes. We evaluated RV-PA coupling by measuring the ratio of right ventricular global longitudinal strain (RVGLS) to pulmonary arterial systolic pressure (PASP), termed the RVGLS/PASP ratio, and assessed its prognostic role using the STrain for Risk Assessment and Therapeutic Strategies in Patients with Acute Heart Failure registry. From an AHF registry of 4312 patients, we analyzed the RVGLS/PASP ratio in 2,865 patients (1,449 men; age, 71.1±13.5 years). At a median follow-up of 35.0 months, 1,199 (41.8%) patients died. Remarkably, PASP (hazard ratio [HR], 1.012; p<0.001), RVGLS (HR, 1.019; p<0.001), and the RVGLS/PASP ratio (HR, 2.426; p<0.001) were statistically significant predictors of all-cause mortality in the univariate analysis. The RVGLS/PASP ratio was a significant predictor of all-cause mortality in all the HF phenotypes, including HF with reduced ejection fraction (HR, 2.124; p=0.002), HF with mildly reduced ejection fraction (HR, 2.733; p=0.021), and HF with preserved ejection fraction (HR, 2.134; p=0.006). Multivariate analysis after adjusting for clinical and echocardiographic variables revealed that the RVGLS/PASP ratio ≤0.32 was associated with a 36% increase in all-cause mortality (HR, 1.365; p<0.001). Impaired RV-PA coupling, defined as an RVGLS/PASP ratio (≤0.32) was associated with an increased risk of mortality in patients with AHF across all HF phenotypes. ClinicalTrials.gov Identifier: NCT03513653.

Right ventricular uncoupling in heart failure with preserved ejection fraction: a simple parameter to predict long-term mortality?

Abstract Introduction Several prognostic models have been developed for risk stratification of mortality in patients with acute heart failure (AHF). eRecent evidence suggests that the right ventricular (RV)-pulmonary artery (PA) uncoupling is associated with poor outcomes in heart failure. Patients with heart failure and preserved ejection fraction (HFpEF) are a heterogeneous population with a wide range of clinical outcomes. However, the prognostic utility of RV-PA uncoupling for predicting long-term mortality in these patients remains elusive. Objective To assess the prognostic value of right ventricle-pulmonary artery coupling for long-term mortality in hospitalized patients with HFpEF. Methods Retrospective analysis of a consecutive, prospective, single-center cohort. Adult patients hospitalized between 2015 and 2020 with a primary diagnosis of AHF and left ventricular ejection fraction (LVEF) &amp;gt;40% were included. The primary endpoint was long-term all-cause mortality. Ventricular uncoupling was assessed as the ratio of tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) estimated from an echocardiogram performed within 3 months of the index hospitalization. Univariable Cox proportional hazards regression models were used to calculate hazard ratios (HR), and multivariable Cox regression was performed with previously analyzed covariates: age, sex, atrial fibrillation, renal dysfunction and E/e'. Results Of 465 patients with HFpEF, 361 (77%) PASP and TAPSE could be estimated simultaneously. During a mean follow-up of 20.9 months, the primary outcome event occurred in 100 patients (27.7%). The optimal cut-off for the primary endpoint was TAPSE/PASP=0.38. Univariable Cox regression showed that RV-PA uncoupling was associated with the primary endpoint of long-term mortality (hazard ratio [HR] 1.96 [95% CI, 1.32-2.92], P=0.001). Kaplan-Meier analysis showed that patients with a ratio &amp;lt;0.38 were at high risk of all-cause mortality (Figure 1). Multivariable analysis also showed that RV-PA uncoupling was significantly associated with long term mortality independent of age, sex, atrial fibrillation, renal dysfunction and E/e' (HR 2.21 [95% CI, 1.26-3.81], P=0.005). Conclusions In patients hospitalized for AHF with preserved ejection fraction, RV-PA uncoupling as determined by the TAPSE/PASP ratio was independently associated with long-term all-cause mortality. TAPSE/PASP was associated with mortality independently of age, sex, renal function, atrial fibrillation and diastolic dysfunction. This simple echocardiographic parameter may identify a population at higher risk for events during follow-up.Kaplan-Meier for all-cause mortality

Abstract 16372: Prognostic Value of Baseline Right Ventricular Dysfunction Using TAPSE and TAPSE to PASP Ratio in Patients Undergoing Mitra-Clip: Systematic Review and Meta-Analysis

Introduction: Transcatheter edge-to-edge mitral valve repair (TEER) using Mitra-clip is an established therapy for high-risk surgical candidates who are refractory to optimal medical treatment. Several reports have shown that right ventricular dysfunction (RVD) is associated with increased morbidity and mortality in heart failure (HF) patients. Emerging data on the relationship between baseline RVD and post-TEER mortality has been published. Objective: Our main goal is to assess the prognostic impact of baseline RV function markers; tricuspid annular plane excursion (TAPSE) and TAPSE/PASP (pulmonary arterial systolic pressure) ratio, as an expression of the right ventricle-pulmonary artery coupling following Mitra-Clip. Methods: MEDLINE and EMBASE were searched for studies discussing outcomes of Mitra-Clip in patients with and without RV dysfunction as expressed by TAPSE or TAPSE:PASP ratio. Two reviewers independently screened the studies and extracted the pertinent survival data. Odds ratios (OR) with 95% confidence interval were calculated using a random-effects model. Results: Twelve reports enrolling 3515 patients (1443 with and 2072 without pre-existing RVD) were included. Patients with RVD had OS reduction after Mitra-Clip by 55% at 6 months, 60% at one year, and 63% at two years [OR: 0.45 (0.35-0.58), 0.40 (0.33-0.48), 0.37 (0.31-0.45) respectively; P &lt; .001] compared to normal RV group. Likewise, HR readmission free survival was minimized among RVD patients by 53% at 6 months, 56% at one year, and 59% at two years compared to normal RV group [OR: 0.47 (0.35-0.65), 0.44 (0.35-0.55), 0.41 (0.30-0.56) respectively; P &lt; .00001]. TAPSE:PASP ≤ 0.30-0.37 was associated with lower OS and HF re-admission free survival at 6 months (OR: 0.37, 0.44; P &lt; .00001) and 1 year (OR: 0.35, 0.41; P &lt; .00001) after Mitra-Clip. Furthermore, TAPSE ≤ 15-16 negatively impacted the OS at 6 months (OR: 0.40 P &lt; .00001) and 1 year (OR: 0.50; P &lt; .00001) after Mitra-Clip. Conclusions: Pre-existing RV dysfunction as expressed by TAPSE ≤15-16 or TAPSE:PASP ratio ≤ 0.30-0.37 decreased the overall survival and HF readmission free survival after Mitra-Clip therapy. Further research is warranted to guide interventional timing based on the degree of RV dysfunction.

Clinical Value of a Novel Three-Dimensional Echocardiography–Derived Index of Right Ventricle–Pulmonary Artery Coupling in Tricuspid Regurgitation

Echocardiographic surrogates of right ventricle-to-pulmonary artery (RV-PA) coupling have been reported to be associated with outcomes in patients with secondary tricuspid regurgitation (STR). However, pulmonary artery systolic pressure (PASP) is difficult to estimate using echocardiography in patients with severe STR. The aim of the present study was to evaluate the predictive power of a surrogate of RV-PA coupling obtained using right ventricular (RV) volumes measured on three-dimensional echocardiography. One hundred eight patients (mean age, 73±13years; 61% women) with moderate or severe STR were included. At a median follow-up of 24months (interquartile range, 2-48months), 72 patients (40%) had reached the composite end point of death of any cause and heart failure hospitalization. RV-PA coupling was computed as the ratio between RV forward stroke volume (SV) (i.e., RV SV-regurgitant volume) and RV end-systolic volume (ESV). RV forward SV/ESV was significantly more related to the composite end point than RV ejection fraction (area under the curve, 0.85 [95% CI, 0.78-0.93] vs 0.73 [95% CI, 0.64-0.83], respectively; P=.03). A value of 0.40 was found to best correlate with outcome. On multivariate Cox regression, RV forward SV/ESV, tricuspid annular plane systolic excursion/PASP, and RV free wall longitudinal strain/PASP were all independently associated with the occurrence of the composite end point when added to a group of parameters including STR severity (severe vs moderate), atrial fibrillation, pulmonary arterial hypertension, right atrial volume, RV end-diastolic volume, and RV free wall longitudinal strain. RV forward SV/ESV<0.40 (HR, 3.36; 95% CI, 1.49-7.56; P<.01) carried higher related risk than RV free wall longitudinal strain/PASP<-0.42%/mm Hg (HR, 3.1; 95% CI, 1.26-7.84; P=.01) and tricuspid annular plane systolic excursion/PASP<0.36mm/mm Hg (HR, 2.69; 95% CI, 1.29-5.58; P=.01). RV ejection fraction did not correlate independently with prognosis when added to the same group of variables. RV forward SV/ESV is associated with the risk for death and heart failure hospitalization in patients with STR.

Clinical Usefulness of Right Ventricle-Pulmonary Artery Coupling in Cardiovascular Disease.

Right ventricular-pulmonary artery coupling (RV-PA coupling) refers to the relationship between RV contractility and RV afterload. Normal RV-PA coupling is maintained only when RV function and pulmonary vascular resistance are appropriately matched. RV-PA uncoupling occurs when RV contractility cannot increase to match RV afterload, resulting in RV dysfunction and right heart failure. RV-PA coupling plays an important role in the pathophysiology and progression of cardiovascular diseases. Therefore, early and accurate evaluation of RV-PA coupling is of great significance for a patient's condition assessment, clinical decision making, risk stratification, and prognosis judgment. RV-PA coupling can be assessed by using invasive or noninvasive approaches. The aim of this review was to summarize the pathological mechanism and evaluation methods of RV-PA coupling, the advantages and disadvantages of each method, and the application value of RV-PA coupling in various cardiovascular diseases.

Evaluación mediante OCT del remodelado vascular pulmonar en insuficiencia cardiaca avanzada. Estudio OCTOPUS-CHF

Introduction and objectivesPulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data. MethodsThis observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery. ResultsOCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient=0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25mm had significantly higher mean pulmonary pressures (37.00 vs 25.00mmHg; P=.004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P=.017). ConclusionsDirect morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension.

A Simple Echocardiographic Approach in Assessing the Prognosis of Comatose Patients with Acute Intracerebral Hemorrhage by Using Right Ventricle-Pulmonary Artery Coupling.

It remains a challenge to judge whether comatose patients with acute intracerebral hemorrhage (ICH) can wake up. Here, we aimed to investigate the changes in right ventricle-pulmonary artery (RV-PA) coupling over time in these patients and to evaluate its performance for discriminating between those who woke up within 60days and those who did not. Thirty-five comatose patients with acute spontaneous ICH underwent bedside echocardiography on days 1, 3, and 5 after onset with the measurement of tricuspid annular plane systolic excursion and mean pulmonary artery pressure. The RV-PA coupling (the ratio of tricuspid annular plane systolic excursion to mean pulmonary artery pressure) was calculated. Within 60days of the onset of coma, 11 individuals awakened and survived, and 24 individuals died. In awakened patients, RV-PA couplings did not differ among days 1, 3, and 5 (1.62 ± 0.38 vs. 1.61 ± 0.32 vs. 1.64 ± 0.25mm/mm Hg, P > 0.05), whereas in unawakened patients, they decreased drastically from day 1 to day 3 and then to day 5 (1.26 ± 0.32 vs. 0.63 ± 0.05 vs. 0.43 ± 0.06mm/mm Hg, P < 0.05). The area under receiver operating characteristic curve of 0.992 for the ratio of RV-PA coupling on day 5 to day 1 of the coma was superior to that for the Glasgow Coma Scale (area under receiver operating characteristic curve of 0.606) in the discrimination of comatose patients with ICH who woke up within 60days from those who did not. The optimal cutoff value was 0.536, with a sensitivity of 100.00%, a specificity of 96.24%, and an accuracy of 97.13%. Right ventricle-pulmonary artery coupling demonstrated a high performance for discriminating comatose patients with ICH who woke up within 60days from those who did not.

Prognostic power of a new index of right ventricle-pulmonary artery coupling based on right ventricular volumes in patients with secondary tricuspid regurgitation

Abstract Background Although echocardiographic surrogates of right ventricular -arterial coupling (RVAC) have been reported to be associated with outcome in patients with moderate or severe secondary tricuspid regurgitation (STR), pulmonary artery systolic pressure (SPAP) is difficult to be estimated using echocardiography in patients with severe STR. Purpose Accordingly, we evaluated the predictive power of indexes of RVAC obtained using RV volumes measured using three-dimensional echocardiography (3DE). Methods We prospectively enrolled 180 patients with moderate or severe STR and complete two-dimensional, Doppler and 3DE data. The composite endpoint of death for any cause and heart failure hospitalization was used as primary outcome. Results After a median follow up of 24 months (IQR: 2–48), 72 patients (40%) reached the primary endpoint. Most of the echocardiographic parameters of RV function were associated with outcomes. Among the different parameters of RVAC, the receiver operating curve (ROC) analysis selected the ratio between (RV stroke volume [SV]-RegVol)/ RV End-systolic volume (ESV) (i.e. the RV forward SV/ESV) as the best predictor of the combined endpoint (AUC 0.80 [IC 95% 0.73–087]), with a threshold value of 0.49. Event-free survival of patients with RV forward SV/ESV higher and lower 0.49 has been performed (Figure 1). Multivariable Cox proportional hazards models were constructed (Figure 2). Adding sequentially the 3D-RVEF, TAPSE/SPAP and the forward RV SV/RV ESV on top of a basal model made of TR severity, New York Heart Association (NYHA) functional class and tricuspid anulus plane systolic excursion (TAPSE), the χ2 of the model increased from 40 to 43 (p=0.13) by adding 3D RVEF, from 43 to 46 (p=0.04) by adding TAPSE/SPAP, and from 46 to 51 (p=0.02) by adding RV forward SV/ESV. Severe TR (HR 3.53 [CI 95%: 1.84–6.78], p&amp;lt;0.001) and RV forward SV/ESV &amp;lt;0.49 (HR 2.45 [CI 95% 1.16–5.18], p=0.02) were the only parameters independently associated with outcome. Conclusions The RV forward SV/ESV is an index of RVAC obtained by 3DE which is independent from SPAP and it is strongly associated with the occurrence of death or heart failure hospitalization in patients with STR. Funding Acknowledgement Type of funding sources: None.

Optical coherence tomography assessment of pulmonary vascular remodeling in advanced heart failure. The OCTOPUS-CHF study

Introduction and objectivesPulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data. MethodsThis observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery. ResultsOCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient=0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25mm had significantly higher mean pulmonary pressures (37.00 vs 25.00mmHg; P=.004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P=.017). ConclusionsDirect morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension.

Expert consensus on the diagnosis and treatment of severe and critical coronavirus disease 2019.

Expert consensus on the diagnosis and treatment of severe and critical coronavirus disease 2019.

Impact of Right Ventricle-Pulmonary Artery Coupling on Clinical Outcomes in the PARTNER 3 Trial.

Physiologic right ventricle-pulmonary artery (RV-PA) coupling may be impaired in patients with aortic stenosis (AS). This study aimed to assess the incidence and prognostic significance of impaired RV-PA coupling in low-risk patients with symptomatic severe AS undergoing transcatheter aortic valve replacement or surgical aortic valve replacement. RV-PA coupling was measured by transthoracic echocardiography as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) in patients in the PARTNER (Placement of Aortic Transcatheter Valve) 3 trial. The primary endpoint was the composite of all-cause mortality, stroke, and rehospitalization at the 2-year follow-up. Among 570 low-risk patients included in the analysis, RV-PA uncoupling was defined by a TAPSE/PASP ratio≤ 0.55mm/mmHg. At baseline, 222 of 570 (38.9%) patients had RV-PA uncoupling. At 2 years, patients with baseline RV-PA uncoupling had an increased incidence of the primary endpoint (19.1% vs 9.9%, P = 0.002), all-cause mortality (5.9% vs 0.6%, P< 0.001), cardiovascular mortality (4.1% vs 0.6%, P = 0.003), and rehospitalization (13.5% vs 7.3%, P = 0.018). On multivariable analysis, baseline RV-PA uncoupling remained an independent predictor of the primary endpoint at 2 years (HR: 1.92; 95%CI: 1.04-3.57; P = 0.038). In patients with symptomatic severe AS at low surgical risk undergoing transcatheter aortic valve replacement or surgical aortic valve replacement, baseline RV-PA uncoupling defined by TAPSE/PASP ≤ 0.55mmHg was associated with adverse clinical outcomes at 2 years, including all-cause mortality, cardiovascular mortality, and rehospitalization.

TCT-414 Impact of Transcatheter Edge-to-Edge Repair on Right Ventricle-Pulmonary Artery Coupling in Patients With Functional Mitral Regurgitation

TCT-414 Impact of Transcatheter Edge-to-Edge Repair on Right Ventricle-Pulmonary Artery Coupling in Patients With Functional Mitral Regurgitation

Imaging in Pulmonary Vascular Disease-Understanding Right Ventricle-Pulmonary Artery Coupling.

The right ventricle (RV) and pulmonary arterial (PA) tree are inextricably linked, continually transferring energy back and forth in a process known as RV-PA coupling. Healthy organisms maintain this relationship in optimal balance by modulating RV contractility, pulmonary vascular resistance, and compliance to sustain RV-PA coupling through life's many physiologic challenges. Early in states of adaptation to cardiovascular disease-for example, in diastolic heart failure-RV-PA coupling is maintained via a multitude of cellular and mechanical transformations. However, with disease progression, these compensatory mechanisms fail and become maladaptive, leading to the often-fatal state of "uncoupling." Noninvasive imaging modalities, including echocardiography, magnetic resonance imaging, and computed tomography, allow us deeper insight into the state of coupling for an individual patient, providing for prognostication and potential intervention before uncoupling occurs. In this review, we discuss the physiologic foundations of RV-PA coupling, elaborate on the imaging techniques to qualify and quantify it, and correlate these fundamental principles with clinical scenarios in health and disease. © 2022 American Physiological Society. Compr Physiol 12: 1-26, 2022.

Right ventricle systolic function and right ventricle-pulmonary arterycoupling in patients with severe aortic stenosis and the early impact of TAVI.

Few data are available on the prevalence of right ventricle (RV) systolic dysfunction, assessed including RV strain, and RV to pulmonary artery (PA) coupling in patients with aortic stenosis (AS) submitted to TAVI and the early effect of the procedure. We performed standard and speckle tracking echocardiography in 80 patients with severe AS the day before TAVI and within 48h after TAVI. In all patients we measured TAPSE/PASP (cut-off for RV-PA uncoupling 0.31) and in 60/80 we were able to analyze RV global longitudinal strain (RV-GLS) and RV free wall strain (RV-FWS). RVFAC and TAPSE were impaired in 8.3% while RV-GLS and RV-FWS in 45% and 33.3%respectively before TAVI. TAPSE/PASP < 0.31 was documented in 7/80 patients (8.7%) before TAVI. These subjects differed from patients with TAPSE/PASP ≥ 0.31 for: enlarged left ventricular (LV) end-diastolic and end-systolic volumes (p < 0.001), worst LVejection fraction (p < 0.001) and RVFAC (p < 0.001), worst RV-GLS and RV-FWS (p = 0.01 and p = 0.03) and bigger right atrium (RA) area (p < 0.001). After TAVI, RV systolic function did not improve while PASP significantly decreased (p = 0.005) driving the improvement of TAPSE/PASP (p = 0.01). Patients with TAPSE/PASP improvement (51%) differed from the others for worst pre-TAVI diastolic function (E/e' p = 0.045), RVFAC (p = 0.042), RV-GLS (p = 0.049) and RA area (p = 0.02). RV-GLS unveils RV systolic dysfunction in as much as 45% of patients with AS vs only 8.3% revealed by conventional echocardiography. RV systolic function does not significantly improve early after TAVI while RV-PA coupling does. Patients with lower TAPSE/PASP at baseline have worst LV and RV systolic function as well as larger RA. Patients who improve TAPSE/PASP after TAVI are those with worst diastolic function, RV systolic function and larger RA at baseline.

Right ventricle-pulmonary artery coupling in repaired tetralogy of fallot with pulmonary regurgitation: clinical implications

Abstract Funding Acknowledgements Type of funding sources: None. Background The right ventricle-pulmonary artery (RV-PA) coupling is a strong prognostic marker in several clinical settings, but only few studies focused on its role in repaired Tetralogy of Fallot (rToF) with pulmonary regurgitation (PR). Aim of this study was to assess whether differences exist in RV-PA coupling, estimated as by echocardiography, between patients with rToF and PR with (i-PVR) or without (ni-PVR) indication for pulmonary valve replacement (PVR). 3 Materials and Methods The study population included 40 rToF patients allocated to two groups: 20 i-PVR and 20 ni-PVR; 40 healthy controls were also included. All subjects underwent echocardiogram, while Cardiac magnetic resonance (CMR) was available in 27/40 rToF patients. RV-PA coupling was assessed by echocardiographic TAPSE/PASP and RV stroke volume/RV end systolic volume (RVSV/RVESV) by CMR. Results TAPSE was similar in i-PVR vs ni-PVR (19.0 ± 3.4 vs 18.8 ± 2.7 mm, p = 0.85) while RV-PA coupling was significantly worse in i-PVR vs ni-PVR (TAPSE/PASP 0.8 ± 0.3 vs 1.1 ± 0.5 mm/mmHg, p = 0.009) as well as in i-PVR vs controls (p = 0.02) while there was no difference between ni-PVR and controls (p = 0.29). CMR data confirmed the echo results, with a significant difference in RV-PA coupling between i-PVR and ni-PVR (RVSV/RVESV 0.9 ± 0.2 vs 1.2 ± 0.3 mL/min/mL, p = 0.01). Conclusions This study shows the presence of worse RV-PA uncoupling, despite normal RV systolic function, in rToF patients with indication to PVR. RV-PA coupling could be a sensitive marker of a progressive maladaptive RV response to long-standing volume overload in rToF prior to the onset of clinical symptoms and RV systolic dysfunction. Abstract Figure. example of an i-PVR patient

Right ventricle-pulmonary artery coupling in repaired tetralogy of Fallot with pulmonary regurgitation: Clinical implications

Right ventricle-pulmonary artery (RV-PA) coupling is a strong prognostic marker in several clinical settings, but few studies have focused on its role in repaired tetralogy of Fallot (rToF) with pulmonary regurgitation. To assess whether differences exist in RV-PA coupling, estimated by echocardiography, between patients with rToF and pulmonary regurgitation with or without an indication for pulmonary valve replacement (PVR). The study population included 40 patients with rToF, who were allocated to two groups: 20 with an indication for PVR (i-PVR group); and 20 without an indication for PVR (ni-PVR group). Forty healthy controls were also included. All subjects underwent echocardiography, and cardiac magnetic resonance (CMR) was available in 27/40 patients with rToF. RV-PA coupling was assessed by echocardiographic tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure (TAPSE/PASP) and right ventricular stroke volume/right ventricular end-systolic volume (RVSV/RVESV) by CMR. TAPSE was similar in the i-PVR and ni-PVR groups (19.0±3.4 vs 18.8±2.7mm; P=0.97) whereas RV-PA coupling was significantly worse in the i-PVR group versus the ni-PVR group (TAPSE/PASP 0.8±0.3 vs 1.1±0.5mm/mmHg; P=0.001), and in the i-PVR group versus the control group (P=0.02); there was no difference between the ni-PVR and control groups (P=0.29). CMR data confirmed the echocardiography results, with a significant difference in RV-PA coupling between the i-PVR and ni-PVR groups (RVSV/RVESV 0.9±0.2 vs 1.2±0.3mL/min/mL; P=0.01). This study demonstrates worse RV-PA coupling, despite normal RV systolic function, in patients with rToF with an indication for PVR. RV-PA coupling could be a sensitive marker of a progressive maladaptive RV response to long-standing volume overload in rToF before the onset of clinical symptoms and RV systolic dysfunction.