Ventricular-pulmonary Arterial Coupling Research Articles

Non-Invasive Evaluation of Right Ventricular Pulmonary Artery Coupling Ratio as a Risk Stratification Tool for Patients with HFpEF

Non-Invasive Evaluation of Right Ventricular Pulmonary Artery Coupling Ratio as a Risk Stratification Tool for Patients with HFpEF

Comparison of prognostic value among echocardiographic surrogates of right ventricular-pulmonary arterial coupling: A three-dimensional echocardiographic study.

Right ventricular (RV)-pulmonary arterial (PA) coupling is important in various cardiac diseases. Recently, several echocardiographic surrogates for RV-PA coupling have been proposed and reported to be useful in predicting outcomes. However, it remains unclear which surrogate is the most clinically relevant. This study aimed to comprehensively compare the prognostic value of different echocardiographic RV-PA coupling surrogates. We retrospectively reviewed 242 patients with various cardiac conditions who underwent comprehensive transthoracic echocardiography with three-dimensional RV data. In addition to conventional parameters including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and PA systolic pressure (PASP), we analyzed RV free wall and global longitudinal strain (FWLS and GLS). We also obtained RV ejection fraction (RVEF), stroke volume (SV), and end-systolic volume (ESV) using three-dimensional RV analysis. RV-PA coupling surrogates were calculated as TAPSE/PASP, FAC/PASP, FWLS/PASP, GLS/PASP, RVEF/PASP, and SV/ESV. The study endpoint was a composite outcome of all-cause death or cardiovascular hospitalization within 1 year. In multivariable analysis, all the RV-PA coupling surrogates were independent predictors of the outcome. Among the surrogates, the model with TAPSE/PASP showed the lowest prognostic value in model fit and discrimination ability, whereas the model with RVEF/PASP exhibited the highest prognostic value. The partial likelihood ratio test indicated that the model with RVEF/PASP was significantly better than the model with TAPSE/PASP (p<.024). All the RV-PA coupling surrogates were independent predictors of the outcome. Notably, RVEF/PASP had the highest prognostic value among the surrogates.

Novel Echocardiographic Measurements of Right Ventricular-Pulmonary Artery Coupling in Predicting the Prognosis of Precapillary Pulmonary Hypertension.

Currently, there are many parameters with proven prognostic significance in pulmonary hypertension (PH). Recently, the parameters defining right ventricular-pulmonary artery coupling (RVPAC) have gained clinical importance. In our study, we investigated the prognostic potential of previously known single echocardiographic parameters and new parameters reflecting RVPAC in patients with precapillary PH. Our study aimed to evaluate the prognostic value of selected echocardiographic parameters and the neutrophil-lymphocyte ratio (NLR) in adults with precapillary PH. This study included 39 patients (74% women; average age, 63 years) with precapillary PH: pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). The mean follow-up period was 16.6 ± 13.3 months. Twelve patients (31%) died during the observation time. We measured several echocardiographic parameters, which reflect right ventricular function, pulmonary hemodynamics, and RVPAC. To assess disease progression and the patient's functional capacity, the World Health Organization functional class (WHO FC) was determined. The patient's physical capacity was also evaluated using the 6 min walk test (6MWT). The analysis included values of the N-terminal prohormone brain natriuretic peptide (NT-proBNP) and NLR. TAPSE × AcT and TAPSE/sPAP were shown to statistically and significantly correlate with PH predictors, including WHO-FC, 6MWT, and NT-proBNP. Univariate Cox proportional hazards regression analysis revealed that AcT, TAPSE, mPAP, TAPSE/sPAP, RAP, TRPG/AcT, TAPSE × AcT, and NLRs are good predictors of mortality in patients with PH. In addition, the ROC curve analysis showed that TAPSE × AcT is a better predictor of PH-related deaths than TAPSE/sPAP and TAPSE alone. In our study, patients with TAPSE × AcT values < 126.36 had shorter survival times (sensitivity = 72.7%; specificity = 80.0%). TAPSE × AcT is a novel, promising, and practicable echocardiographic parameter reflecting RVPAC, which is comparable to TAPSE/sPAP. Moreover, TAPSE × AcT can be a useful parameter in assessing the severity and prognosis of patients with precapillary PH.

Right ventricular-pulmonary artery coupling and in-hospital mortality of patients with first acute coronary syndrome

Abstract Background Right ventricular-pulmonary artery (RV-PA) coupling is a means of indexing RV performance to the existent RV afterload. Although non-invasive analysis of RV-PA coupling is a well-recognized prognosticator in chronic RV pressure overload conditions such as heart failure and pulmonary hypertension, its impact in patients with myocardial infarction and acute elevations in RV afterload remains undetermined. Aim This study sought to investigate the associations and short term prognostic value of RV-PA coupling in patients with first acute coronary syndrome (ACS), as assessed by two standard echocardiographic measurements: tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP). Methods A total of 300 consecutive patients with first ACS (mean age 61.2±11.8 years, 74% males) were prospectively enrolled. A comprehensive transthoracic echocardiographic assessment was undertaken within 24 hours after revascularization. In-hospital mortality was the study endpoint. The study population was dichotomized according to the optimal TAPSE/PASP cut-off, as determined by receiver-operating characteristic curve analysis. Univariable and multivariable logistic regression analysis was performed to determine predictors of impaired TPASE/PASP and the association of TAPSE/PASP with in-hospital mortality. To further assess the incremental prognostic value of TAPSE/PASP over a baseline model the change in x² was assessed using the likelihood ratio test. Results A total of 23 (7.7%) patients died in-hospital despite successful revascularization. The optimal cut-off value of TAPSE/PASP to determine in-hospital mortality was 0.49. Among others, univariable associates of impaired TAPSE/PASP were the Global Registry of Acute Coronary event (GRACE) risk score, Killip Class &amp;gt;2, late presentation after symptoms onset, NT-pro-BNP, and left ventricular ejection fraction (LVEF). In multivariable analysis LVEF was the only independent predictor of impaired TAPSE/PASP (OR 0.889, 95% CI [0.821-0.963], p=0.004). The subgroup of patients with LVEF&amp;lt;40% and TAPSE/PASP&amp;lt;0.49mm/mmHg exhibited the worst in-hospital mortality rate (Abstract Picture 1). TAPSE/PASP was significantly associated with in-hospital mortality (OR 0.037, 95% CI [0.009-0.153], p&amp;lt;0.001), and retained this association after adjusting for GRACE risk score and LVEF (OR 0.137, 95% CI [0.032-0.578], p=0.007). The incremental prognostic value of TAPSE/PASP&amp;lt;0.49mm/mmHg for in-hospital mortality was evaluated by adding it to a model including the GRACE risk-score, LVEF&amp;lt;40% and TAPSE&amp;lt;17mm. The further addition of impaired TAPSE/PASP significantly increased the x² of the model from 21.627 to 86.213, p&amp;lt;0.001 (Abstract Picture 2). Conclusion RV-PA coupling assessed non-invasively by echocardiography 24 hours after revascularization was an independent predictor of in-hospital mortality in patients with first ACS and may improve risk stratification.In hospital mortality ratesIncremental prognostic value

Acyl ghrelin increases cardiac output and preserves right ventricular-pulmonary arterial coupling in patients with heart failure

Abstract Background Pulmonary hypertension and right ventricular (RV) failure are common in heart failure with reduced ejection fraction (HFrEF). Acyl ghrelin improves cardiac output (CO) in HFrEF but when CO increases there is a risk of increased pulmonary vascular resistance (PVR). This may impair the right ventricular-pulmonary artery coupling (RVPAC) and in the long term further harm the afterload sensitive RV in HFrEF or in patients with pulmonary arterial hypertension (WHO group 1). Animal data suggest that acyl ghrelin has beneficial effects on the pulmonary vasculature. Purpose To investigate if grehlin increases CO without worsening the right-sided hemodynamics in HFrEF assessed by RVPAC measured as the non-invasive surrogate tricuspid annular plane systolic excursion/tricuspid regurgitation velocity (TAPSE/TRV). Methods The Karolinska Acyl Ghrelin Trial (ClinicalTrials.gov NCT05277415) was a double-blind placebo-controlled trial of acyl ghrelin vs. placebo in HFrEF. In this secondary analysis we assessed RVPAC. Patients (n = 15+15) received either acyl ghrelin 30 pmol/kg/min or placebo (normal saline) intravenously during 120 min. Echocardiography exams at baseline and 120 min were assessed for RV parameters and patients were included if both TAPSE and TRV could be assessed at both time-points. Changes within groups (acyl ghrelin and placebo) at baseline vs. 120 min were analysed by Wilcoxon rank sign test. Analysis of variance was used to test for difference in change acyl ghrelin vs. placebo, adjusted for baseline values. Results A total of 22 patients (acyl ghrelin n = 12, placebo = 10) were included. Clinical characteristics were similar [median (IQR) acyl ghrelin vs. placebo): age 71 (65-77) vs. 74 (72-77) years, EF 29 (20-35) vs. 18 (13-36) %. Despite a 15% increase in CO in the acyl ghrelin group [from 4.0 (3.5-4.6) to 4.6 (3.9-6.1) L/min, p = 0.003], RVPAC remained unchanged; 5.9 (5.3-7.6) to 6.3 (4.8-7.5) mm·(m/s)-1, p = 0.372, while it was reduced in the placebo group, 5.2 (4.3-6.4) to 4.8 (4.2-5.8) mm·(m/s)-1, p = 0.035. Similarly, TAPSE remained unchanged in the acyl ghrelin group 18.0 (14.8-20.5) to 17.5 (13.8-19.3), p = 0.188, while it decreased in the placebo group 14.5 (13.0-17.5) to 13.5 (11.3-15.0), p = 0.028. There were no differences in TRV. When comparing the changes between groups adjusted for baseline, CO increased in the acyl ghrelin group vs. placebo (p = 0.036) while there were no significant differences in RVPAC or TRV (Figure 1). Conclusion These preliminary findings indicate that acyl ghrelin may preserve or even improve RVPAC without increasing the RV pressure gradient. This may be due to acyl ghrelin causing improved contractility, reduced PVR and/or reduced left sided filling pressures. These potential effects strengthen the role of acyl ghrelin therapy in HFrEF and suggest potentially beneficial effects also in patients with isolated or combined pre- and post-capillary pulmonary hypertension.

Right ventricular pulmonary arterial coupling in patients with implanted left ventricular assist devices

Abstract Background Both the right ventricular (RV) contractile function and pulmonary arterial (PA) pressure influence clinical outcomes in patients supported with left ventricular assist devices (LVADs), but the impact of RV-PA coupling is unknown. Purpose This study aimed to determine the prognostic impact of RV-PA coupling in patients with implanted LVADs. Methods Patients with implanted third-generation LVADs were retrospectively enrolled. The RV-PA coupling was assessed preoperatively by the ratio of RV free wall strain (RVFWS) and noninvasively measured peak RV systolic pressure (RVSP). The primary endpoint was a composite of all-cause mortality or right heart failure (RHF) hospitalization. Secondary endpoints consisted of all-cause mortality at a 12-month follow-up and RHF hospitalization. Results A total of 72 patients with good RV myocardial imaging were included. The median age was 57 years, 67 patients (93.1%) were men and 41 (56,9%) had dilated cardiomyopathy. A receiver-operating characteristic analysis (AUC 0.703, 51.5% sensitivity, 94.9% specificity) was used to identify the optimal cutoff point (0.28%/mmHg) for the RVFWS/TAPSE threshold. Event rates were estimated using the Kaplan-Meier method showing an association with an increased risk for the primary endpoint of death or RHF hospitalization (89.47% vs. 30.19%, p&amp;lt;0.001). A similar observation applied to all-cause mortality (47.37% vs. 13.21%, p=0.003) and RHF hospitalization (80.43% vs. 20%, p&amp;lt;0.001). Conclusion An advanced RV dysfunction assessed by RV-PA coupling may serve as a predictor of adverse outcomes in patients with implanted LVADs.

Right ventricular-pulmonary artery coupling in the early stages of infarction could optimize patient risk stratification over five years

Abstract Background Right ventricular (RV) dysfunction is recognized as a cardinal prognostic marker in heart failure (HF) patients. Myocardial infarction (MI) is often followed by unrecognized RV dysfunction, which can be associated with worse outcome. It is recently shown that the ratio between TAPSE and PASP (RV/PA) may depict cardiopulmonary hemodynamics better than the two parameters alone. Aim To evaluate the interactions between left ventricular (LV) and RV function in early phase of MI and to assess the prognostic significance of RV/PA coupling in patients with first MI during 5 years follow up. Methods The prospective study included 144 patients with the first MI treated with the primary percutaneous coronary intervention (p PCI) who underwent Doppler echocardiography within 2±1 days of MI. LV function analysis included: LV ejection fraction (EF), ratio between early diastolic velocity and tissue annular velocity (E/e) and global longitudinal strain (GLS). RV function and RV-PA interaction was expressed as ratio between TAPSE and PASP. During the five-year follow-up, major cardiovascular events and especially hospitalization for HF were analyzed. Results Progressive RV/PA uncoupling was associated with higher degree of LV impairment and dysfunction (EF p&amp;lt;0.001, E/e p=0.002, GLS p&amp;lt;0.001) and severity of mitral regurgitation (p=0.013). Lower baseline RV/PA coupling significantly reflects the frequency of hospitalizations for HF in the population of patients with first MI during five-year follow-up (0.62 v.s.0.51, p=0.021). After multivariate adjustment RV/PA remained an independent predictor of all major cardiac events (MACE) after five years (OR 14.0 [1.5–130.8], p=0.019). Conclusion A lower baseline RV-PA coupling, reflecting a higher degree of LV-induced pulmonary hypertension and secondary RV-dysfunction, is associated with decline of LV function in early phase of MI, and is independently associated with worse prognosis after five years. The value of RV-PA ratio as an prognstic marker warrants further investigation.

Right ventricular-pulmonary arterial coupling for predicting death or heart failure admission in a broad population of patients with severe tricuspid regurgitation: data from the INTRICOR registry

Abstract Background The role of right ventricular-pulmonary arterial coupling, non-invasively evaluated by means of the tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) ratio in prognostic assessment of tricuspid regurgitation (TR) has been studied only in selected populations and mainly for all-cause mortality. Purpose To investigate the value of TAPSE/PASP ratio for predicting the combined end-point of mortality and heart failure (HF) admission in follow-up in a broad population of patients with severe TR, and to compare its discriminative ability with both components of the index separately. Methods We included retrospectively all consecutive patients ≥18 years with severe TR studied with echocardiography in a tertiary care hospital from 01.01.2008 to 31.12.2017, followed up to 01.01.2022. Association of TAPSE/PASP ratio with the combined end point and comparative discrimination ability with both components of the index was investigated. The net reclassification indexes for events (NRIe) and non-events (NRIne) were also calculated, with variables dichotomized at median values for establishing risk groups. Results A total 661 patients (69±13 years, 72% women) with severe TR, followed for up to 14 years (median 5 years, p25-75 2-7 years) were included in the cohort, with 384 deaths and 268 patients with 636 HF admissions on follow up. Median (p25-75) values for TAPSE/PASP, TAPSE and PASP were 0.34 (0.25-0.44) mm/mmHg, 18 (16-20) mm and 53 (43-65) mmHg, respectively. All three variables were associated with the combined outcome in univariate analysis (figure 1). Discriminative abilities for predicting the endpoint (figure 2A) were statistically significant for all, but TAPSE/PASP performed significantly better than both components separately (p&amp;lt;0.0005). However, after adjusting by other statistically significant prognostic variables, TAPSE/PSAP was not found to be an independent predictor (HR 0.711 [0.091-5.555], p=0.75), whereas both components of the index remained in the model (HR 0.945 [0.919-0.972], p&amp;lt;0.0005 for TAPSE and HR 1.012 [1.007-1.018], p&amp;lt;0.0005 for PASP). The discriminative performance of the three multivariate models including each variable was statistically significant for all (figure 1B) but the model including TAPSE/PASP perfomed similarly to the one including TAPSE (p=0.86) and worse than the one including PASP ((p=0.02). The NRIe and NRIne for TAPSE/PASP versus TAPSE were 5.0% and 0.5%; and 0.4% and 1.3% versus PSAP; these values for multivariate models including TAPSE/PSAP versus TAPSE were 3.1% and 0.4%; and 3.6% and 1.6% versus PASP. Conclusions In this broad sample of patients with severe TR, TAPSE/PASP ratio was associated with HF admission or mortality in univariate analysis, and its discriminative ability was higher than any of both components of the index. However, it was not an independent predictor in multivariate analysis.Kaplan-Meier CurvesROC curves

Effects of inhaled seralutinib on right ventricular-pulmonary arterial (RV-PA) coupling and right heart function in pulmonary arterial hypertension (PAH)

Abstract Background Impaired RV-PA coupling portends a poor prognosis in PAH, and right ventricular free wall strain/systolic pulmonary artery pressure (RVFWS/sPAP) has been reported as a measure of RV-PA coupling. Furthermore, increased RVFWS and right atrial area (RAA), as well as decreased pulmonary artery compliance (PAC) are associated with increased mortality risk in PAH. Seralutinib is a novel, small molecule kinase inhibitor that targets PDGFR, CSF1R, and c-KIT administered via dry powder inhaler. TORREY, a phase 2, double-blind, randomised, placebo-controlled study of inhaled seralutinib in patients with PAH (NCT04456998) met its primary endpoint, demonstrating a significant reduction in pulmonary vascular resistance (PVR) from baseline (BL) to Week 24 compared to placebo. In addition, seralutinib significantly decreased NT-proBNP. Purpose To test the hypothesis that seralutinib would improve RVFWS/sPAP and other measures of right heart function after 24 weeks of treatment compared to placebo in the TORREY study. Methods Eighty-six patients with WHO Group 1 PH (Functional Class II, III), ages ≥18 years, pulmonary vascular resistance ≥400 dyne*s/cm5, and on stable PAH standard of care therapy (the majority of whom were on double and triple therapy with approved PAH medications) were enrolled. Right heart catheterisation (RHC) and full echocardiography were performed at BL and Week 24 and at BL, Week 12, and Week 24, respectively; both were analysed in a blinded central laboratory. To calculate RVFWS/sPAP, the pulmonary artery systolic pressure from RHC was used. PAC was calculated from RHC data with the formula (SV/(PAS-PAD)). Statistical analysis was performed using ANCOVA. Results At Week 24, the change in RVFWS/sPAP was lower in the seralutinib group compared to placebo (Table). The changes in RVFWS and RAA were lower in the seralutinib group vs placebo at Week 12 and Week 24 (Table). Change in NT-proBNP correlated with change in RAA (r = 0.43). At Week 24, change in PAC was greater in the seralutinib group (-0.02 ± 0.085 placebo, 0.19 ± 0.089 seralutinib; LSMD 0.22 (0.104) p = 0.04). There was no effect of seralutinib on left ventricular ejection fraction. Conclusion Treatment with seralutinib was associated with a significant reduction of RVFWS/sPAP. In addition, significant differences in RVFWS itself, RAA, and PAC were observed. These treatment effects support improved RV-PA coupling and right heart function. In conjunction with concordant reductions in PVR and NT-proBNP, these data suggest potential favourable effects of seralutinib in PAH. Seralutinib is in clinical development as a potential new treatment option for patients with PAH.

Right ventricular-arterial coupling and exercise-induced tricuspid regurgitation

Abstract Background Right Ventricular-pulmonary Artery (RV-PA) coupling is prognostic in a variety of cardiovascular disorders, including heart failure with preserved ejection fraction, pulmonary hypertension and severe aortic stenosis. The functional aspects of RV-PA coupling are less investigated than rest ones especially in what is their interaction with tricuspid regurgitation (TR). Purpose We sought to understand the association of RV-PA coupling with extent of exercise induced TR by combining gas exchange abnormalities through cardiopulmonary exercise test (CPET) imaging. Methods We prospectively studied patients with indication to perform a CPET imaging test due to dyspnoea and underlying heart disease of any left ventricular ejection fraction. Demographics, baseline characteristics, echo and CPET parameters [(e.g. VE/VCO2 slope and peak oxygen consumption (pVO2)] were evaluated across 3 sub-cohorts phenotyped according to TR severity pattern at rest and at peak exercise . Mitral and tricuspid regurgitation degree were adjudicated accordingly to ESC guidelines. RV-PA coupling function was assessed through the ratio between tricuspid annular plane systolic excursion (TAPSE), and non-invasive pulmonary artery systolic pressure (PASP) with echocardiography. Dynamic TR was defined as detection of at least moderate TR grade from rest to stress. Results A total of 73 patients (age 67±13 years, 52% men), with a mean LVEF of 50±14% were studied. Overall 50 (69%) patients had less than moderate TR which did not increase during stress (Controls), 11 (15%) patients exhibited a dynamic TR pattern (Group 1), and 12 (16%) already had significant TR at rest (Group 2). TAPSE/PASP at rest and peak exercise were significantly lower in Group 1 and 2 compared to Controls (Figure), while the mean PAP/cardiac output (CO) ratio at rest and at peak exercise were significantly higher (Table). As to gas exchange data, Group 1 and 2 exhibited a lower median peak VO2, while Group 2 patients had also a higher median VE/VCO2 slope compared to Controls (Table). 10 (14%) patients showed at least moderate mitral regurgitation (significant MR) at rest and the prevalence of significant MR at peak was higher in group 1 and 2 compared to Controls (Table). A weak negative correlation was found between TAPSE/PASP slope and E/e’ ratio at peak exercise (r =-0.435, p&amp;lt;0.01). Conclusion In presence of exercise dyspnoea, patients with dynamic TR during maximal exercise exhibit a worse degree of RV-PA coupling and gas exchange profile compared to the group without significant exercise-induced TR. Moreover, the exercise-induced TR profile behaves similarly to the one of those presenting with moderate to severe TR already detectable at rest. Phenotyping dynamic TR and RV-PA warrants further evidence on therapies and outcomes prediction in exertional dyspnoea patients.FigureTable

Abstract 13061: Association of Right Ventricular - Pulmonary Arterial Coupling and Progression of Tricuspid Regurgitation in Patients With Non-Valvular Atrial Fibrillation

Introduction: Tricuspid regurgitation (TR) severity in patients with atrial fibrillation (AF) is associated with poor prognosis. Recently, right ventricular-pulmonary arterial (RV-PA) coupling has been shown to be related to clinical outcomes in TR patients. However, data on the relationship of RV-PA coupling to the progression of significant TR is limited. Hypothesis: This study aimed to investigate whether RV-PA coupling affects the progression of significant TR in patients with non-valvular AF. Methods: A total of 300 consecutive AF patients with insignificant TR were included among 371 patients with AF who underwent follow-up echocardiography. Insignificant TR was defined as TR less than a mild degree. We excluded other significant valvular diseases, regional wall motion abnormality, LVEF &lt;50%, the cardiac implantable electronic device, cardiac surgery, and poor echo image for RV analysis. RV-PA coupling was assessed by the ratio of RV global longitudinal strain (GLS) using speckle tracking echocardiography to pulmonary artery systolic pressure (PASP). Results: During a mean 4.7±2.5 years of follow-up, 31 (10.3%) patients (mean age 67.5±11.7 years, 37.0% female) have progressed to significant TR as more than moderate degree. The patients who progressed to significant TR were older, more likely to be female, and had a higher prevalence of ischemic stroke, higher PASP, larger RV size, lower right atrial (RA) strain, lower RVGLS, and lower RVGLS/PASP than patients without TR progression. RV-PA coupling reflected by RVGLS/PASP was independently related to the progression of TR after adjusting for age, gender, and history of stroke (p&lt;0.001). It remained significant for predicting TR progression even after further adjustment for PASP, RA strain, or RV strain (Figure). Conclusions: RV-PA coupling was associated with the progression of TR in patients with non-valvular AF, which might suggest that it can be a helpful parameter in monitoring this population.

Pulmonary hypertension and heart failure: alternative indexes of right ventricular-pulmonary artery coupling

Pulmonary hypertension is a serious cardiovascular pathology, often complicating the course of heart failure (HF). Excessive pulmonary artery pressure increases right ventricular afterload and progressively leads to dysfunction, which is associated with adverse outcomes regardless of left ventricular ejection fraction. In this regard, more attention should be paid to determining the right ventricular condition. Currently, in order to assess the right heart function in patients with pulmonary hypertension and HF, the right ventricular (RV)-pulmonary arterial (PA) coupling, is increasingly being used. The conventional formula to calculate this parameter is the ratio of tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP). This index has proven to be a powerful predictor of adverse outcomes. But this calculation method has a number of limitations and can lead to errors. It is extremely important to exclude or minimize any possible inaccuracies during prognostic assessment, which is why new researches of alternative RV-PA calculation options have been recently published. Such things as problems that can occur during TAPSE and PASP evaluation, ways of modifying the assessment of right heart’s functioning in patients with pulmonary hypertension and heart failure have been addressed. The value of new RV-PA alternative «surrogate» indexes has been discussed.

Tricuspid Regurgitation Velocity/Tricuspid Annular Plane Systolic Excursion (TRV/TAPSE) Ratio as a Novel Indicator of Disease Severity and Prognosis in Patients with Precapillary Pulmonary Hypertension.

Tricuspid annular plane systolic excursion (TAPSE) and tricuspid regurgitation velocity (TRV) are two echocardiographic parameters with prognostic value in patients with pulmonary hypertension (PH). When analyzed concurrently as the TRV/TAPSE ratio, they allow the ventricular-pulmonary artery coupling (RVPAC) to be assessed. This could better predict disease severity in patients with PH. Our study aimed to evaluate the prognostic value of the TRV/TAPSE ratio echocardiographic parameter in adults with precapillary PH. This study included 39 patients (74% women; average age, 63 years) with precapillary PH (pulmonary arterial hypertension and chronic thromboembolic PH) The mean follow-up period was 16.6 ± 13.3 months. Twelve patients (31%) died during the observation time. We measured TAPSE as a surrogate of RV contractility and TRV reflecting RV afterload, while ventricular-arterial coupling was evaluated by the ratio between these two parameters (TRV/TAPSE). To assess disease progression and the patient's functional capacity, the World Health Organization functional class (WHO FC) was determined. Patient physical capacity was also evaluated using the 6 min walk test (6MWT). The analysis included values of N-terminal prohormone brain natriuretic peptide (NT-proBNP), which were taken routinely during the follow-up visit. The mean calculated TRV/TAPSE ratio was 0.26 ± 0.08 m/s/mm. Upon comparison of the TRV/TAPSE ratio to the disease prognostic indicators, we observed a statistically significant correlation between TRV/TAPSE and the results of the WHO FC, 6MWT, and NT-proBNP. The TRV/TAPSE ratio is thus a good predictor of mortality in PH patients (AUC, 0.781). Patients with a TRV/TAPSE ratio > 0.30 m/s/mm had a shorter survival time, with log-rank test p < 0.0001. Additionally, ROC analysis revealed higher AUC for TRV/TAPSE than for TAPSE and TRV alone. TRV/TAPSE is a promising practicable echocardiographic parameter reflecting RVPAC. Moreover, TRV/TAPSE could be viable risk stratification parameter and could have prognostic value in patients with PH.

Stressed Blood Volume in Severe Tricuspid Regurgitation: Implications for Transcatheter Treatment

BackgroundAlthough tricuspid transcatheter edge-to-edge repair (TEER) has been suggested to improve outcomes in patients with tricuspid regurgitation (TR), patients remain at substantial residual risk after the intervention. Total blood volume is divided between the unstressed volume, filling the vascular space, and stressed blood volume (SBV), generating intravascular pressure. SBV is an important mediator of hemodynamic derangements in heart failure and might pose an attractive adjunctive treatment target. ObjectivesThe aim of this study was to investigate the role of SBV in patients with severe TR and its implications for tricuspid TEER. MethodsIn total, 279 patients underwent right heart catheterization prior to TEER. SBV was estimated from hemodynamic variables fit to a comprehensive cardiovascular model. ResultsEstimated stressed blood volume (eSBV) was associated with obesity, renal and hepatic dysfunction and cardiac remodeling (P < 0.05 for all). Hemodynamically, eSBV correlated with pulmonary artery and cardiac filling pressures as well as right ventricular–pulmonary artery coupling (P < 0.05 for all). After TEER, patients with eSBV greater than the median demonstrated less reduction in right atrial pressures, peripheral edema, and ascites compared with lower eSBV patients (P < 0.05 for all). Higher eSBV was an independent predictor of the occurrence of death and heart failure hospitalization during a median follow-up duration of 618 days (P < 0.05 for all). ConclusionsIn patients with severe TR, eSBV is associated with obesity, renal and liver dysfunction, more severe heart failure, attenuated reduction of venous congestion after TEER, and adverse clinical outcomes. Estimation of SBV should be incorporated in future trials in the field to identify patients in need of adjunctive therapies.

Comprehensive echocardiographic assessment of right ventricular function, pulmonary arterial elastic properties and ventricular-vascular coupling in adult patients with repaired tetralogy of fallot: clinical significance of 3D derived indices.

We aimed to comprehensively analyze by three-dimensional speckle-tracking echocardiography (3DSTE) and Doppler echocardiography right ventricular (RV) performance, pulmonary arterial (PA) elastic properties and right ventricular-pulmonary artery coupling (RVPAC) in patients with repaired tetralogy of Fallot (rTOF) and assess the feasibility and clinical utility of related echocardiographic indices. Twenty-four adult patients with rTOF and twenty-four controls were studied. RV end-diastolic volume(3D-RVEDV), RV end-systolic volume(3D-RVESV), RV ejection fraction(3D-RVEF), RV longitudinal strain(3D-RVLS) and RV area strain(3D-RVAS) were calculated by 3DSTE. RV end-systolic area (RVESA) was obtained by planimetry. Pulmonary regurgitation (PR) was assessed as trivial/mild or significant by cardiac magnetic resonance (CMR) and color-Doppler. Pulmonary artery (PA) elastic properties were determined using two-dimensional/Doppler echocardiography. RV systolic pressure (RVSP) was measured using standard Doppler methods. RVPAC was assessed using various 3DSTE-derived parameters (3DRVAS/RVSP, 3DRVLS/RVESA, 3DRVAS/RVESV). Overall, 3DRVEF and 3DRVAS were impaired in rTOF patients compared with controls. PA pulsatility and capacitance were reduced (p = 0.003) and PA elastance was higher (p = 0.0007) compared to controls. PA elastance had a positive correlation with 3DRVEDV (r = 0.64, p = 0.002) and 3DRVAS (r = 0.51, p = 0.02). By ROC (receiver operating characteristics) analysis, 3DRVAS/RVESV, 3DRVAS/RVSP and 3DRVLS/RVESA cutoff values of 0.31%/mmHg, 0.57%/mmHg and 0.86%/mmHg, respectively, had 91%, 88% and 88% sensitivity and 81%, 81% and 79% specificity in identifying exercise capacity impairment. In rTOF patients increased 3DSTE-derived RV volumes and impaired RV ejection fraction and strain are associated with reduced PA pulsatility and capacitance and increased PA elastance. 3DSTE-derived RVPAC parameters using different afterload-markers are accurate indices of exercise capacity.

Right ventricular-pulmonary artery coupling ratio derived from 3D echocardiography - better predictor of outcome in patients with precapillary pulmonary hypertension

Abstract Funding Acknowledgements Type of funding sources: None. Background In patients with pulmonary hypertension (PH), right ventricular (RV) function has a well-known prognostic value. Recent data suggest that right ventricular-pulmonary artery (RV-PA) coupling is an independent predictor of outcome in this setting. RV-PA coupling can be assessed invasively as the endsystolic/arterial elastance ratio or noninvasively using surrogates such as CMR-derived RV stroke-volume (SV) to endsystolic volume (ESV) ratio or 2D echocardiography-derived TAPSE/PASP ratio. Data regarding the 3D echocardiography-derived RV SV/ESV as parameter of RV-PA coupling in PH patients are scarce. Purpose To assess the RV-PA coupling as 3DE-RV SV/ESV ratio and its impact on clinical outcome in patients with precapillary PH compared with the validated 2DE-TAPSE/PASP. Methods Thirty-two patients (40±13 years, 27 women) with precapillary PH receiving vasodilator therapy and 25 controls of similar age and gender (37±9 years, 18 women) were studied. Clinical data, BNP levels and RV function parameters (TAPSE, free-RV wall S- and e’-wave, RV FAC, Tei index, RV-IVA, RVEF by 3DE) were assessed. RV global longitudinal strain (RV-GLS) was measured as the average of 6 segments and RV free wall strain as the average of 3 segments by speckle-tracking 2DE. RV-PA coupling was assessed as TAPSE/PASP and 3DE-RV SV/ESV ratios. PH patients were followed for 41 months (2–77). Cardiac death was the endpoint. Results PH patients had impaired 2DE and 3DE RV function parameters and RV-PA coupling compared to controls (p&amp;lt;0.001). At baseline, 3DE-RV SV/ESV and TAPSE/PAPS correlated with each other (r=0.51, p = 0.003) and both correlated with RV function parameters, but only SV/ESV correlated with BNP levels (Table) and WHO functional class (0.71±0.16 in class II, 0.66±0.21 in class III, 0.34±0.14 in class IV, p = 0.01). During follow-up, 5 patients died and these patients had at baseline higher BNP levels (LnBNP 5.91±1.62 vs 4.32±1.29, p = 0.02) and lower values of TAPSE (15±4 vs 18±3 mm, p = 0.03), S-RV (9.2±2.3 vs 11.1±1.8 cm/s, p = 0.04), RV free wall strain (−11.6±6.6 vs −18.1±5.3%, p = 0.02), RVEF (32±11 vs 40±7%, p = 0.04), and SV/ESV (0.49±0.22 vs 0.68±0.19, p = 0.05), but similar values for TAPSE/PASP (0.18±0.10 vs 0.20±0.05 mm/mmHg, p = 0.75). Conclusion In PH patients, 3DE-RV SV/ESV ratio as parameter of RV-PA coupling is altered and correlates with clinical status and RV function parameters. Besides parameters of RV function and BNP levels, 3DE-RV SV/ESV ratio seems a better predictor than TAPSE/PASP in this setting.

Left atrial remodeling and right ventricular-pulmonary arterial coupling after MitraClip implantation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter edge-to-edge mitral valve repair (TEER) with the MitraClip system has emerged as a therapeutic alternative to surgical solutions in high risk patients with severe mitral regurgitation (MR). MR is characterized by left ventricular volume overload, which leads to left ventricular dilatation. Furthermore, MR is a common cause of pulmonary hypertension. Right ventricular (RV) intrinsic contractility and its response to afterload is referred to as RV-pulmonary arterial (PA) coupling. Effect of TEER in patients with MR on left atrial (LA) function and RV-PA coupling is less investigated. Purpose The aim of our study was to assess clinical characteristics of patients undergoing MitraClip implantation including LA function and RV-PA coupling. Methods Eighty-eight consecutive patients with chronic severe MR were enrolled in the single-center observational study (mean age 71.5±7.9 years, male 54.5%, ischemic cardiomyopathy 54.5%). Primary MR (PMR) was present in 22.7%, secondary MR (SMR) in 73.9 % and mixed (MxMR) etiology in 3.4%. Conventional and advanced echocardiography examination was performed using speckle tracking echocardiography before TEER and at 6 month post-TEER follow-up. Left atrial maximal (LAV max) and minimal (LAV min) volumes were measured indexed for body surface area. Furthermore, we analysed left atrial functional parameters, such as reservoir strain, conduit strain and contraction strain. Results The technical success of MitraClip implantation was 95,5%. Mortality rate at 6 month follow-up time was 10.8% (1/88 PMR, 7/88 SMR, 1/88 MxMR). Severe residual MR developed during follow-up in 4.2% and New York Heart Association class III-IV functional status was concluded in 6.8% at 6 month post-TEER. Significant decrease in left ventricular end-diastolic median diameter (mm) was observed at follow-up compared to pre-TEER: 57.5 (IQR: 51.25 – 63.75) vs 60.5 (IQR: 52.5 – 66.75), respectively, p = 0.01. Similarly, the median value of pulmonary artery systolic pressure (PASP) substantially decreased (mmHg) after TEER: 42 (IQR: 32 – 52) vs 49.5 (IQR: 41 – 57), respectively, p = 0.003. Tricuspid annulus systolic excursion/PASP median value, representing RV-PA coupling, improved remarkably: 0.45 (IQR: 0.31 – 0.69) vs 0.38 (IQR: 0.29 – 0.52), respectively, p = 0.02. Compared to pre-TEER, median LA volumes and strain parameters did not change significantly at 6 month post-TEER: reservoir strain (%) 12.88 (IQR: 8.18–18.78) vs 11.74 (IQR: 7.48–20.36), p = 0.41; LAV max (ml) 48.70 (IQR: 39.81–62.29) vs 48.17 (IQR: 42.08–58.7), p = 0.31; LAV min (ml) 34.33 (IQR: 24.5–46.32) vs 33.89 (IQR: 26.02–44.53), p = 0.69. Conclusions The function of the enlarged LA was severely reduced, which did not change after MitraClip implantation in our population. However, positive left ventricular remodeling and improvement in RV-PA coupling was observed 6 month after MitraClip procedure.

Right ventricular-pulmonary arterial coupling in patients with COVID-19: A systematic review and meta-analysis

Objectives: In this systematic review and meta-analysis, we assessed the association between right ventricular-pulmonary arterial (RV-PA) coupling and mortality in coronavirus disease 2019 (COVID-19). Methods: We performed a systematic literature search using MEDLINE (PubMed), Embase, Cochrane and Web of Science. We only included observational studies and randomized controlled trials in which, right ventricular function and pulmonary pressures were investigated, in adult patients with COVID-19. The primary outcome was mortality. The secondary outcome was pulmonary embolism (PE). Random-effects meta-analysis was performed. Mean differences (MD) and unadjusted hazard ratios (HRs) were pooled. Results: 21 studies were included in our systematic review for qualitative analysis, and eight of them qualified for quantitative analysis. Tricuspid annular plane systolic excursion (TAPSE) over pulmonary artery systolic pressure (PASP) (TAPSE/PASP) ratio was significantly lower in non-survivors compared with survivors (mean difference = – 0.28 [–0.38, –0.17], p &lt; 0.00001; I2: 61%, p &lt; 0.08). TAPSE was significantly lower in non- survivors compared with survivors (mean difference = – 3.53 [–4.72, –2.33], p &lt; 0.00001; I2: 77%, p &lt; 0.0005). Lower TAPSE was associated with increased mortality (HR = 0.77 [0.63, 0.94], p &lt; 0.010; I2: 77%, p = 0.01). PASP was significantly higher in non-survivors compared with survivors (mean difference = 9.14 [6.67, 11.61], p &lt; 0.00001; I2: 37%, p=0.18). One study demonstrated a higher risk of mortality for lower TAPSE/PASP in both intensive care unit (ICU) and non-ICU patients and, one study showed that TAPSE/PASP was significantly associated with a higher risk of PE. Conclusion: COVID-19 non-survivors have a significantly worse RV-PA coupling as compared to survivors.

Right ventricular–pulmonary arterial coupling in patients with implanted left ventricular assist devices

ObjectiveBoth the right ventricular (RV) contractile function and pulmonary arterial (PA) pressure influence clinical outcomes in patients supported with left ventricular assist devices (LVADs), but the impact of RV-PA coupling is unknown. This study aimed to determine the prognostic impact of RV-PA coupling in patients with implanted LVADs. MethodsPatients with implanted third-generation LVADs were retrospectively enrolled. The RV-PA coupling was assessed preoperatively by the ratio of RV free wall strain (RVFWS) derived from speckle-tracking echocardiography and noninvasively measured peak RV systolic pressure (RVSP). The primary end point was a composite of all-cause mortality or right heart failure (RHF) hospitalization. Secondary end points consisted of all-cause mortality at a 12-month follow-up and RHF hospitalization. ResultsA total of 103 patients were screened, and 72 with good RV myocardial imaging were included. The median age was 57 years; 67 patients (93.1%) were men, and 41 (56,9%) had dilated cardiomyopathy. A receiver-operating characteristic analysis (AUC 0.703, 51.5% sensitivity, 94.9% specificity) was used to identify the optimal cutoff point (0.28%/mmHg) for the RVFWS/TAPSE threshold. Nineteen subjects (26.4%) had advanced RV-PA uncoupling. Event rates were estimated using the Kaplan-Meier method showing a strong association with an increased risk for the primary end point of death or RHF hospitalization (89.47% vs. 30.19%, p < 0.001). A similar observation applied to all-cause mortality (47.37% vs. 13.21%, p = 0.003) and RHF hospitalization (80.43% vs. 20%, p < 0.001). ConclusionsAn advanced RV dysfunction assessed by RV-PA coupling may serve as a predictor of adverse outcomes in patients with implanted LVADs.

Impact of right ventricular-pulmonary arterial coupling on clinical outcomes in patients undergoing transcatheter aortic valve implantation

AimsThe interplay between pulmonary hypertension (PH) and right ventricular (RV) function is reflected in an index of RV function to pulmonary artery (PA) systolic pressure (PASP). The present study aimed to assess the importance of RV-PA coupling on clinical outcomes after transcatheter aortic valve implantation (TAVI). Methods and resultsIn a prospective TAVI registry, clinical outcomes of TAVI patients with RV dysfunction or PH were stratified according to coupling or uncoupling of tricuspid annular plane systolic excursion (TAPSE) to PASP, and compared to those of patients with normal RV function and absence of PH. The median TAPSE/PASP ratio was used to differentiate uncoupling (>0.39) from coupling (<0.39). Among 404 TAVI patients, 201 patients (49.8 %) had RVD or PH at baseline: 174 patients had RV-PA uncoupling, and 27 had coupling at baseline. RV-PA hemodynamics normalized in 55.6 % of patients with RV-PA coupling and in 28.2 % of patients with RV-PA uncoupling, and deteriorated in 33.3 % of patients with RV-PA coupling and in 17.8 % of patients with no RVD, respectively, at discharge. Patients with RV-PA uncoupling after TAVI showed a trend towards an increased risk of cardiovascular death at 1 year as compared to patients with normal RV-function (HRadjusted 2.06, 95 % CI 0.97–4.37). ConclusionAfter TAVI, RV-PA coupling changed in a significant proportion of patients and is a potentially important metric for risk stratification of TAVI patients with RVD or PH. Tweet“Patients with right ventricular dysfunction and pulmonary hypertension are at increased risk of death after TAVI. Integrated right ventricular to pulmonary artery hemodynamics change after TAVI in a significant proportion of patients and is instrumental to refine risk stratification.” Clinical trial registrationhttps://www.clinicaltrials.gov: NCT01368250.