Prognostic value of combined left and right ventricular-arterial coupling after transcatheter aortic valve implantation

Abstract Introduction Ventricular-arterial (VA) coupling can be assessed non-invasively by echocardiography using the ratio of tricuspid annular plane systolic excursion to systolic pulmonary artery pressure (TAPSE/SPAP) for the right heart and the ratio of left ventricular end-systolic volume to stroke volume (LVESV/SV) for the left heart. Both have shown prognostic value in patients undergoing transcatheter aortic valve implantation (TAVI). However, the value of combining both right and left VA coupling and specifically when assessed after TAVI is unknown. Aim To evaluate the association between post-TAVI left and right VA uncoupling and long-term clinical outcomes. Methods This retrospective cohort study included 728 patients who underwent TAVI between November 2007 and December 2019. No patients were lost to follow-up. The study focused on all-cause deaths occurring within 60 months after TAVI, with exact times of death recorded. Post-TAVI VA coupling values were obtained from the first echocardiographic assessment during follow-up after discharge, performed within 180 days post-procedure. The cut-off values of 0.39 for TAPSE/SPAP and 0.36 for LVESV/SV were determined through receiver operating characteristic analysis, considering 5-year all-cause mortality. Patients were categorized into three groups: Group 1 (no VA uncoupling, n=200), Group 2 (unilateral VA uncoupling, either right or left, n=411), and Group 3 (bilateral VA uncoupling, both right and left, n=117). Uni- and multivariable Cox regression analyses were used to investigate the independent prognostic value of these groups. Results The cohort’s median age was 81 years (IQR: 76–85), with 53% male. Of 728 patients, 268 (37%) died within five years. Group 3 patients had the worst echocardiographic profiles, including higher left atrial volume index, impaired (absolute values reported) left ventricular global longitudinal strain, elevated SPAP, and more frequent significant concomitant mitral and tricuspid regurgitation at baseline (Table) . These patients also had higher rates of coronary artery disease and atrial fibrillation (Table). On the univariable Cox regression and Kaplan-Meier curve analyses, post-TAVI bilateral VA uncoupling was associated with worse prognosis (Figure). After adjusting for potential confounders in the multivariable Cox regression analysis (including baseline clinical characteristics and post TAVI echocardiographic characteristics), no VA uncoupling (HR: 0.468, 95% CI: 0.289-0.757, p = 0.002) and unilateral VA uncoupling (HR: 0.707, 95% CI: 0.502-0.984, p = 0.040) remained independently associated with better survival as compared to bilateral VA uncoupling. Conclusion No VA uncoupling and unilateral VA uncoupling after TAVI are independently associated with significantly better long-term survival compared to bilateral VA uncoupling and may be therefore used to improve risk stratification and management of patients after TAVI.Table.Population Characteristics Figure