Follow‐up tricuspid annular plane systolic excursion predicts survival in pulmonary arterial hypertension

Abstract

Few studies have examined the utility of serial echocardiography in the evaluation, management, and prognosis of patients with pulmonary arterial hypertension (PAH). Therefore, we sought to evaluate the prognostic significance of follow-up tricuspid annular plane systolic excursion (TAPSE) in PAH. We prospectively studied 70 consecutive patients with PAH who underwent baseline right heart catheterization (RHC) and transthoracic echocardiogram, who survived to follow-up echocardiogram after initiation of PAH therapy. Baseline TAPSE was 1.6 ± 0.5 cm which increased to 2.0 ± 0.4 cm on follow-up (P < 0.0001). The cohort was dichotomized by TAPSE at one-year follow-up: Group 1 (n = 37): follow-up TAPSE ≥ 2 cm; Group 2 (n = 33): follow-up TAPSE < 2 cm. Group 1 participants were significantly more likely to reach WHO functional class I–II status and achieve a higher six-minute walk distance on follow-up. Of the 68 patients who survived more than one year, 18 died (26.5%) over a median follow-up of 941 days (range, 3–2311 days), with significantly higher mortality in Group 2 versus Group 1 (41.9% vs. 13.5%; P = 0.003). While baseline TAPSE stratified at 2 cm did not predict survival in this cohort, TAPSE ≥ 2 cm at follow-up strongly predicted survival in bivariable models (hazard ratio, 0.21; 95% confidence interval, 0.08–0.60). In conclusion, follow-up TAPSE ≥ 2 cm is a prognostic marker and potential treatment target in a PAH population.

Echocardiographic Assessment of the Right Ventricle–State of the Art

“…The key strength of TAPSE is its simplicity as it can be measured on all ultrasound machines. It has been shown to have prognostic value in a variety of conditions which may affect the RV such as heart failure with preserved or reduced ejection fraction [20] and pulmonary hypertension [21]. As with all regional assessments of function, the obvious assumption made is that the longitudinal function of the RV free wall is indicative of function of the RV as a whole.…”

What Echocardiography Can Reliably Tell Us About Our Pulmonary Hypertension Patients

“…Specifically, follow-up TAPSE ≥ 2 cm was associated with a decrease in all-cause mortality (hazard ratio = 0.21, 95% CI = 0.08, 0.60) and improved WHO functional class and 6-minute walk distance. 18 Prior to a study published by Sivak et al, it was unclear how much right atrial function contributed to RV function. Because total RV function is largely due to longitudinal shortening, Sivak et al hypothesized that the increased distance between RV base and apex that occurs during right atrial systole is an important contributor to overall RV function.…”

Differences in right ventricular morphology, not function, indicate the nature of increased afterload in pulmonary hypertensive subjects with normal left ventricular function

“…Further work will need to be done on how RV morphology changes over time, especially in patients with PH PVD , where reverse RV remodeling will transform RV morphology closer to normal. Prior work has shown that RV dimension, area, and the RV:LV ratio decline with PAH treatment . However, these studies did not focus specifically on changes in the sRV b/a over time.…”

“…Prior work has shown that RV dimension, area, and the RV:LV ratio decline with PAH treatment. 30,31 However, these studies did not focus specifically on changes in the sRV b/a over time. Future studies are also needed to evaluate the relationship between RV morphology and RV strain measures, as well as the reliability of sRV b/a to predict pulmonary vascular disease in patients with heart failure with poor LV function with LVEF < 50%.…”