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

Gavazzoni, Mara; Badano, Luigi P.; Cascella, Andrea; Heilbron, Francesca; Tomaselli, Michele; Caravita, Sergio; Baratto, Claudia; Perelli, Francesco; Radu, Noela; Perger, Elisa; Parati, Gianfranco; Muraru, Denisa

doi:10.1016/j.echo.2023.06.014

Cited by 19 publications

(8 citation statements)

References 60 publications

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“…Lower TAPSE/PASP coupling ratios were independently associated with decreased survival in patients with TR undergoing transcatheter repair, where it outperformed TAPSE or PASP alone [ 38 ]. However, given the limitations of both TAPSE and PASP measurement in severe TR [ 11 , 39 , 40 ], other coupling surrogates (e.g., stroke volume/end systolic volume) using 3D RV volumes have been investigated and show prognostic utility [ 41 ].…”

Section: Discussionmentioning

confidence: 99%

The value of right ventricular to pulmonary arterial coupling in the critically ill: a National Echocardiography Database of Australia (NEDA) substudy

Bowcock,

Huang,

Yeo

et al. 2024

Ann. Intensive Care

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Background Right ventricular (RV) function is tightly coupled to afterload, yet echocardiographic indices of RV function are frequently assessed in isolation. Normalizing RV function for afterload (RV-PA coupling) using a simplified ratio of tricuspid annular plane systolic excursion (TAPSE)/ tricuspid regurgitant velocity (TRV) could help to identify RV decompensation and improve risk stratification in critically ill patients. This is the first study to explore the distribution of TAPSE/TRV ratio and its prognostic relevance in a large general critical care cohort. Methods We undertook retrospective analysis of echocardiographic, clinical, and mortality data of intensive care unit (ICU) patients between January 2012 and May 2017. A total of 1077 patients were included and stratified into tertile groups based on TAPSE/TRV ratio: low (< 5.9 mm.(m/s)−1), middle (≥ 5.9–8.02 mm.(m/s)−1), and high (≥ 8.03 mm.(m/s)−1). The distribution of the TAPSE/TRV ratio across ventricular function subtypes of normal, isolated left ventricular (LV), isolated RV, and biventricular dysfunction was explored. The overall prognostic relevance of the TAPSE/TRV ratio was tested, including distribution across septic, cardiovascular, respiratory, and neurological subgroups. Results Higher proportions of ventricular dysfunctions were seen in low TAPSE/TRV tertiles. TAPSE/TRV ratio is impacted by LV systolic function but to a lesser extent than RV dysfunction or biventricular dysfunction. There was a strong inverse relationship between TAPSE/TRV ratio and survival. After multivariate analysis, higher TAPSE/TRV ratios (indicating better RV-PA coupling) were independently associated with lower risk of death in ICU (HR 0.927 [0.872–0.985], p < 0.05). Kaplan–Meier analysis demonstrated higher overall survival in middle and high tertiles compared to low tertiles (log rank p < 0.0001). The prognostic relevance of TAPSE/TRV ratio was strongest in respiratory and sepsis subgroups. Patients with TAPSE/TRV < 5.9 mm (m/s)−1 had a significantly worse prognosis than those with higher TAPSE/TRV ratios. Conclusion The TAPSE/TRV ratio has prognostic relevance in critically ill patients. The prognostic power may be stronger in respiratory and septic subgroups. Larger prospective studies are needed to investigate the role of TAPSE/TRV in pre-specified subgroups including its role in clinical decision-making.

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Section: Discussionmentioning

confidence: 99%

The value of right ventricular to pulmonary arterial coupling in the critically ill: a National Echocardiography Database of Australia (NEDA) substudy

Bowcock,

Huang,

Yeo

et al. 2024

Ann. Intensive Care

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“…Of note, non-invasive assessment of RV to pulmonary artery coupling was validated in HF populations 86,87 and it seems to be a prognostic predictor of outcome also in medically or percutaneously treated patients with TR. 88,89 Cardiac output assessment is mandatory during RHF evaluation because it provides information on cardiac function and also allows, in relationship with pulmonary and capillary wedge pressures, to calculate pulmonary vascular resistance. The Fick method (indirect or, when feasible, direct) for cardiac output assessment is preferable.…”

Section: Right Heart Catheterizationmentioning

confidence: 99%

Epidemiology, pathophysiology, diagnosis and management of chronic right‐sided heart failure and tricuspid regurgitation. A clinical consensus statement of the Heart Failure Association (HFA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

Adamo,

Chioncel,

Pagnesi

et al. 2024

European J of Heart Fail

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Right‐sided heart failure and tricuspid regurgitation are common and strongly associated with poor quality of life and an increased risk of heart failure hospitalizations and death. While medical therapy for right‐sided heart failure is limited, treatment options for tricuspid regurgitation include surgery and, based on recent developments, several transcatheter interventions. However, the patients who might benefit from tricuspid valve interventions are yet unknown, as is the ideal time for these treatments given the paucity of clinical evidence. In this context, it is crucial to elucidate etiology and pathophysiological mechanisms leading to right‐sided heart failure and tricuspid regurgitation in order to recognize when tricuspid regurgitation is a mere bystander and when it can cause or contribute to heart failure progression. Notably, early identification of right heart failure and tricuspid regurgitation may be crucial and optimal management requires knowledge about the different mechanisms and causes, clinical course and presentation, as well as possible treatment options.The aim of this clinical consensus statement is to summarize current knowledge about epidemiology, pathophysiology and treatment of tricuspid regurgitation in right‐sided heart failure providing practical suggestions for patient identification and management.This article is protected by copyright. All rights reserved.

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“…The ratio between RV systolic function parameters and the Doppler-estimated pulmonary arterial systolic pressure (PASP) [TAPSE/PASP or RV free wall longitudinal strain (RVFWLS)/PASP] has been proposed as a surrogate for the invasively determined RV-pulmonary artery (PA) coupling. 59 Despite the limited accuracy of PASP estimation in massive/torrential STR characterized by a large effective regurgitant orifice area with low-flow velocity and rapid equalization of the RV and RA pressures, 60 , 61 TAPSE/PASP < 0.36 mm/mmHg and RVFWLS/PASP < −0.42%/mmHg have been associated with worse outcomes in medically treated patients with clinically relevant TR, 62 whilst TAPSE/PASP < 0.39–0.41 mm/mmHg was associated with increased mortality after TTVI. 61 , 63 A RV-PA coupling using TAPSE and invasively measured PASP (proposed cut-offs of <0.29–0.30 mm/mmHg) 60 , 61 improved the outcome prediction compared with the non-invasive TAPSE/PASP.…”

Section: Imaging Challenges and Practical Tips For Evaluating Patient...mentioning

confidence: 99%

“…total RV stroke volume—tricuspid regurgitant volume) and RV end-systolic volume by 3D echocardiography (RV forward stroke volume/end-systolic volume proposed cut-off of <0.40) was more strongly associated with outcome than non-invasive TAPSE/PASP and RVFWLS/PASP in patients with clinically relevant STR. 62 Three-dimensional transoesophageal echocardiography can reveal anatomic details of TV leaflets not readily apparent by conventional transthoracic approach (small leaflet prolapse, flail, endocarditis, CIED interference, supernumerary scallops, gap localization, and size), which may refine the classification of TR phenotype and help the decision-making regarding TV repair. 14 …”

Section: Imaging Challenges and Practical Tips For Evaluating Patient...mentioning

confidence: 99%

Atrial secondary tricuspid regurgitation: pathophysiology, definition, diagnosis, and treatment

Muraru,

Badano,

Hahn

et al. 2024

European Heart Journal

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Atrial secondary tricuspid regurgitation (A-STR) is a distinct phenotype of secondary tricuspid regurgitation with predominant dilation of the right atrium and normal right and left ventricular function. Atrial secondary tricuspid regurgitation occurs most commonly in elderly women with atrial fibrillation and in heart failure with preserved ejection fraction in sinus rhythm. In A-STR, the main mechanism of leaflet malcoaptation is related to the presence of a significant dilation of the tricuspid annulus secondary to right atrial enlargement. In addition, there is an insufficient adaptive growth of tricuspid valve leaflets that become unable to cover the enlarged annular area. As opposed to the ventricular phenotype, in A-STR, the tricuspid valve leaflet tethering is typically trivial. The A-STR phenotype accounts for 10%–15% of clinically relevant tricuspid regurgitation and has better outcomes compared with the more prevalent ventricular phenotype. Recent data suggest that patients with A-STR may benefit from more aggressive rhythm control and timely valve interventions. However, little is mentioned in current guidelines on how to identify, evaluate, and manage these patients due to the lack of consistent evidence and variable definitions of this entity in recent investigations. This interdisciplinary expert opinion document focusing on A-STR is intended to help physicians understand this complex and rapidly evolving topic by reviewing its distinct pathophysiology, diagnosis, and multi-modality imaging characteristics. It first defines A-STR by proposing specific quantitative criteria for defining the atrial phenotype and for discriminating it from the ventricular phenotype, in order to facilitate standardization and consistency in research.

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

Cited by 19 publications

References 60 publications

The value of right ventricular to pulmonary arterial coupling in the critically ill: a National Echocardiography Database of Australia (NEDA) substudy

The value of right ventricular to pulmonary arterial coupling in the critically ill: a National Echocardiography Database of Australia (NEDA) substudy

Epidemiology, pathophysiology, diagnosis and management of chronic right‐sided heart failure and tricuspid regurgitation. A clinical consensus statement of the Heart Failure Association (HFA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

Atrial secondary tricuspid regurgitation: pathophysiology, definition, diagnosis, and treatment

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