Impact of right ventricular-pulmonary arterial coupling on clinical outcomes of tricuspid regurgitation

Sugiura, Akira; Kavsur, Refik; Spieker, Maximilian; Iliadis, Christos; Mauri, Victor; Tanaka, Tetsu; Goto, Tadahiro; Weber, Marcel; Kelm, Malte; Baldus, Stephan; Nickenig, Georg; Westenfeld, Ralf; Pfister, Roman; Becher, Marc Ulrich

doi:10.4244/eij-d-22-00045

Cited by 9 publications

(11 citation statements)

References 25 publications

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“…We found no periprocedural mortality, and TR reduction to 2+ or less was observed in 78% of patients, which is comparable to previous reports [ 11 , 12 ]. Although an adequate reduction in TR may lead to an improved outcome [ 2 , 13 ], the prognostic benefit of TR treatment may also be affected by concomitant RV function [ 14 , 15 ]. Furthermore, TR reduction with TTVR might be linked to a risk of afterload mismatch of the RV after the procedure, especially in patients with inherent RV impairment [ 16 ].…”

Section: Discussionmentioning

confidence: 99%

Refining accuracy of RV–PA coupling in patients undergoing transcatheter tricuspid valve treatment

Sugiura,

Tanaka,

Kavsur

et al. 2023

Clin Res Cardiol

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Background Assessing right ventricular (RV) function is paramount for risk stratification, which remains challenging in patients with tricuspid regurgitation (TR). We assessed RV–pulmonary artery (PA) coupling and its predictability of outcomes after transcatheter tricuspid valve repair (TTVR). Methods Study participants comprised patients undergoing transcatheter tricuspid valve repair to treat symptomatic TR from June 2015 to July 2021. We calculated an RV–PA coupling ratio using a formula, which is dividing tricuspid annular plane systolic excursion (TAPSE) by echocardiographically estimated (ePASP) or invasively measured PASP (iPASP) at baseline. The primary outcome was all-cause mortality or heart failure rehospitalization within one year. Results The study participants (n = 206) were at high surgical risk (EuroSCORE II: 7.4 ± 4.8%). The primary outcome occurred in 57 patients within one year. The c-statistics for the outcome were 0.565 (95% CI 0.488–0.643) for TAPSE/ePASP and 0.695 (95% CI 0.631–0.759) for TAPSE/iPASP. The correlation between the ePASP and iPASP was attenuated in patients with massive/torrential TR compared to those with severe TR (interaction p = 0.01). In the multivariable Cox proportional model, TAPSE/iPASP was inversely associated with the risk of the primary outcome (per 0.1-point increase: adjusted-HR 0.67, 95% CI 0.56–0.82, p < 0.001), independent of baseline demographics. According to the TAPSE/iPASP quartiles (i.e., ≤ 0.316; 0.317–0.407; 0.408–0.526; ≥ 0.527), the event-free survival was 43.4%, 48.3%, 77.9%, and 85.4% at one year after TTVR. Conclusion RV–PA coupling predicts one-year mortality and heart failure rehospitalization after TTVR in patients with TR. The predictability is improved if invasively-measured PA pressure is included. Graphical abstract Assessing right ventricular (RV) function is paramount for risk stratification. The present analysis confirms that RV–PA coupling, measured as TAPSE/PASP, predicts one-year mortality and heart failure rehospitalization in patients undergoing TTVR. There is a significant interaction between TR severity and the correlation of ePASP with iPASP, and therefore the correlation is attenuated in patients with massive to torrential TR. The predictability of RV–PA coupling is improved if PA pressure is measured invasively and included in the formula.

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Section: Discussionmentioning

confidence: 99%

Refining accuracy of RV–PA coupling in patients undergoing transcatheter tricuspid valve treatment

Sugiura,

Tanaka,

Kavsur

et al. 2023

Clin Res Cardiol

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“…Guazzi et al 18 . initially proposed using echocardiography‐derived TAPSE/PASP as a non‐invasive measure of RV–PA coupling and demonstrated its role as a distinct indicator of poor outcomes in patients with HF; multiple studies have confirmed this parameter's validity 12,19,34–37 …”

Section: Assessment Of Right Ventricular–pulmonary Arterial Couplingmentioning

confidence: 99%

Application of an echocardiographic index to characterize right ventricular–pulmonary arterial coupling in heart failure

Chen,

Zhang,

Lou

et al. 2024

ESC Heart Failure

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Heart failure (HF), with its high morbidity and mortality, remains a global public health issue. Right ventricular (RV) dysfunction is a sign of deterioration in the natural history of HF, and a thorough evaluation of the relationship between RV contractility and its afterload through RV–pulmonary arterial (RV–PA) coupling can aid in accurately assessing overall RV function. The ratio of RV end‐systolic elastance (Ees) to pulmonary arterial elastance (Ea) invasively measured by right heart catheterization served as the gold standard for evaluating RV–PA coupling. An echocardiographic index termed tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) has been shown to correlate well with Ees/Ea. TAPSE/PASP is recognized as a non‐invasive surrogate of RV–PA coupling and has been extensively studied in patients with HF. This review briefly describes the methods of assessing RV–PA coupling, mainly discussing echocardiography, summarizes the clinical utility of TAPSE/PASP in patients with different HF types, and provides an overview of the available literature.

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“…Despite attempts to phenotype this heterogeneous group of symptomatic TR patients noninvasively, patients referred to centers for intervention benefit from invasive hemodynamics for more accurate characterization of intracardiac filling pressures, biventricular function, as well the severity and mechanism of PH. 4,[10][11][12]22 Invasive hemodynamics revealed that all patients had significant elevations in right and left heart filling pressures despite the use of one or more diuretics upon referral, reflecting an advanced disease state. Previous predictors of clinical success such as pulmonary vascular resistance and RV-PA uncoupling were nonsignificant.…”

Section: Comparison Between Tteer Vs Tmteermentioning

confidence: 99%

“…Patients referred for transcatheter intervention of the tricuspid valve are a highly heterogeneous group with multiple TR etiologies, multiple potential confounding comorbidities, and varying degrees of symptomatology 4,6,10,11 . While it has been reported that different cohorts with severe TR have worse outcomes, we have yet to define reliable hemodynamic predictors for clinical success and patient improvement after TTEER 4,10–12 . Accordingly, the goals of this study were to describe the invasive right heart catheterization (RHC) findings in patients with severe TR undergoing TTEER and identify characteristics of patients who experience immediate symptomatic improvement following TTEER compared to those who do not.…”

Section: Introductionmentioning

confidence: 99%

“…we have yet to define reliable hemodynamic predictors for clinical success and patient improvement after TTEER. 4,[10][11][12] Accordingly, the goals of this study were to describe the invasive right heart catheterization (RHC) findings in patients with severe TR undergoing TTEER and identify characteristics of patients who experience immediate symptomatic improvement following TTEER compared to those who do not.…”

Section: Introductionmentioning

confidence: 99%

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Right heart catheterization predictors of symptomatic improvement in patients undergoing transcatheter tricuspid valve edge‐to‐edge repair

Rezkalla

Reddy

Nishimura

et al. 2023

Cathet Cardio Intervent

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Background Transcatheter tricuspid valve edge‐to‐edge repair (TTEER) is associated with improvement in outcomes for symptomatic patients with severe tricuspid regurgitation (TR). However, reliable predictors for clinical success are not yet fully defined. This study aims to describe right heart catheterization (RHC) findings in patients referred for TTEER and identify hemodynamic characteristics of patients who experience immediate symptomatic improvement following successful TR intervention. Methods Patients who underwent TTEER and had a separate RHC within the preceding 6 months were included. Hemodynamic tracings from the RHC and TTEER procedures were reviewed and recorded. Clinical success was defined as a successful device implant with at least 1‐grade of TR reduction and improvement in NYHA class by 1 or more grades on 30‐day echocardiogram and clinical follow‐up. Results Thirteen patients underwent an RHC within 6 months of TTEER procedure (median age 76 years [IQR: 73–80]). All patients were on a stable dose of loop diuretics. Baseline right atrial pressure was severely elevated (mean 19 mmHg [IQR: 9–24 mmHg]) with prominent CV waves. Median pulmonary capillary wedge pressure (PCWP) was 20 mmHg (IQR: 14–22) and 70% of patients had a mean PCWP > 15 mmHg at rest. Median PCWP CV‐wave was 34 mmHg (IQR: 23–42). Higher PCWP CV‐wave height (40 mmHg [IQR 33–43] versus 18 mmHg [IQR 17–31]) was associated with lower likelihood of clinical success (OR 0.83, 95% CI: 0.35–0.97, p = 0.04). Conclusions Inclusion of invasive hemodynamics as part of pre‐TTEER evaluation may allow for improved TR phenotyping and patient selection. Patients with a large left atrial CV wave on resting RHC were less likely to experience immediate symptomatic improvement despite procedural success with TTEER.

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Impact of right ventricular-pulmonary arterial coupling on clinical outcomes of tricuspid regurgitation

Cited by 9 publications

References 25 publications

Refining accuracy of RV–PA coupling in patients undergoing transcatheter tricuspid valve treatment

Refining accuracy of RV–PA coupling in patients undergoing transcatheter tricuspid valve treatment

Application of an echocardiographic index to characterize right ventricular–pulmonary arterial coupling in heart failure

Right heart catheterization predictors of symptomatic improvement in patients undergoing transcatheter tricuspid valve edge‐to‐edge repair

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