A simple echocardiographic estimate of right ventricular-arterial coupling to assess severity and outcome in pulmonary hypertension on chronic lung disease

Abstract

A simple echocardiographic estimate of right ventricular-arterial coupling to assess severity and outcome in pulmonary hypertension on chronic lung diseaseTo the Editor:The adaptation of right ventricular (RV) systolic function to afterload is a major determinant of outcome in pulmonary hypertension [1]. The gold standard measurement of RV-pulmonary arterial (PA) coupling is the ratio of end-systolic to arterial elastances (E es /E a ) which is optimal for RV flow output at minimal energy cost at values between 1.5 and 2 [2]. Progressive RV-PA uncoupling is associated with maintained RV dimensions down to E es /E a values of around 0.8 [3]. Thus, the evaluation of RV-PA coupling would theoretically allow monitoring of the transition from compensated to decompensated RV function in pulmonary hypertension. However, measuring RV-PA coupling at the bedside is technically demanding and invasive. Therefore, simpler imaging surrogates are being evaluated. One of those is the ratio of tricuspid annular plane systolic excursion (TAPSE) as a surrogate of contractility and systolic pulmonary artery pressure (PASP) as a surrogate of afterload, both measured using echocardiography (M-mode for TAPSE and Doppler assessment of the maximum velocity of tricuspid regurgitation for PASP) [4]. The TAPSE/PASP ratio has emerged as a potent predictor of outcome in heart failure [5] as well as in pulmonary arterial hypertension (PAH) [6].Pulmonary hypertension secondary to chronic lung diseases (PH-LD) is most often mild to moderate, with many patients having a mean pulmonary artery pressure (PAP) <35 mmHg. A small percentage of patients referred for evaluation in dedicated centres may have severe pulmonary hypertension with mean PAP in the range reported in PAH [7]. However, RV function is often altered even in mild-to-moderate PH-LD, and is an important determinant of survival and functional status in PH-LD [7,8]. We therefore explored the functional significance and prognostic relevance of the TAPSE/PASP ratio in PH-LD.We analysed patients with PH-LD and idiopathic PAH (iPAH) enrolled in the prospectively recruiting Giessen PH Registry [9]. The diagnosis of PH-LD was established by a multidisciplinary board before enrolment in the Giessen PH registry [9] between December 2004 and March 2012. Follow-up data were retrieved from the Giessen PH Registry up to February 2018. The analysis included consecutive patients with complete echocardiographic (day 1) and invasive haemodynamic data (day 2) and complete follow-up. The patients with iPAH (n=193) were a subset of a previously reported cohort of 290 patients with PAH [6]. The investigation was approved by the ethics committee of the Faculty of Medicine at the University of Giessen (Approval No. 186/16, 266/11). All participating patients gave written informed consent.As recently updated [7], PH-LD was defined by a mean PAP of ⩾21 mmHg (21-24 mmHg with pulmonary vascular resistance (PVR) ⩾3 Wood Units, or ⩾25 mmHg alone), with mean PAP ⩾35 mmHg alone or mean PAP ⩾25 mmHg with low cardiac ...

Advanced risk stratification of intermediate risk group in pulmonary arterial hypertension

“…TAPSE/PASP is a reproducible marker for right ventricular-arterial coupling which is a well-known predictor of mortality in PH. 12 – 15 We suggest that including right ventricular-arterial coupling mirrored by TAPSE/PASP increases the reliability of the presented method. Both 6MWD and TAPSE/PASP are non-invasive parameters that can be determined easily.…”

Right Ventricular-Arterial Uncoupling Independently Predicts Survival in COVID-19 ARDS

“…Subsequent studies con rmed its prognostic capability, not only in heart failure (21) but also in pulmonary arterial hypertension (22) and in patients with chronic lung diseases (23). In these studies, the TAPSE/PASP was assumed to inform about RV-PA coupling, with TAPSE considered as a load-dependent surrogate of Ees and PASP as an indirect estimate of Ea (21)(22)(23). The TAPSE/PASP has been shown to be superior to other composite echocardiographic indices in the assessment of RV-PA and correlated to gold standard invasive (11) or indirectly assessed Ees/Ea ratios.…”

“…The TAPSE/PASP ratio was initially proposed as an estimate of RV myocardial length-tension relationship, and as such showed to be of prognostic relevance in heart failure (20). Subsequent studies con rmed its prognostic capability, not only in heart failure (21) but also in pulmonary arterial hypertension (22) and in patients with chronic lung diseases (23). In these studies, the TAPSE/PASP was assumed to inform about RV-PA coupling, with TAPSE considered as a load-dependent surrogate of Ees and PASP as an indirect estimate of Ea (21)(22)(23).…”

Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS

“…The TAPSE/PASP ratio was initially proposed as an estimate of RV myocardial length-tension relationship and as such showed to be of prognostic relevance in heart failure [21]. Subsequent studies confirmed its prognostic capability, not only in heart failure [22] but also in pulmonary arterial hypertension [23] and in patients with chronic lung diseases [24]. In these studies, the TAPSE/PASP was assumed to inform about RV-PA coupling, with TAPSE considered as a loaddependent surrogate of Ees and PASP as an indirect estimate of Ea [22][23][24].…”