Value of tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio as a predictor of outcomes in patients supported with long-term left ventricular assist device

Long-term left ventricular assist device (LVAD) support is an increasing therapy in patients with heart failure. Right heart failure (RHF) is associated with mortality and morbidity in these patients and various invasive and non-invasive parameters have been studied to predict early RHF. The tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP) ratio is a surrogated indicator of right ventricle-pulmonary artery coupling that has proven to be an independent predictor of survival in patients with pulmonary hypertension and HF, however, it has not been shown to predict early RHF after LVAD implantation. The aim of this study is to evaluate the TAPSE/PASP ratio as a predictor of RHF and mortality in patients receiving LVAD support. Additionally, we evaluated the predictive value of other hemodynamic parameters: Pulmonary elastance, right ventricle work index, right atrium pressure/ pulmonary capillary wedge pressure (RA/PCWP) ratio, cardiac index, pulmonary vascular resistance, and pulmonary artery pulsatility index (PAPI). We conducted an observational, retrospective study with a cohort of 37 patients that received LVAD support (HeartMate 3®) in our center between 2018 and 2024. The non-invasive TAPSE/PASP ratio was measured before the implant by transthoracic echocardiography (TTE) and correlated with its invasive measurement. To evaluate the potentially prognostic parameters, the threshold value was estimated by ROC curves and Youden index. Survival analysis was made for both time to death and time to combined death or RHF. All patients were male, 65% with ischemic cardiopathy and a medium age of 64 years at time of implant. The LVAD purpose was destination therapy (63%), bridge to transplant (17%) or bridge to decision (10%). After a medium follow-up of 880 days, 6 patients (14%) have died (2 for early RHF, 3 for sepsis and 1 for hemorrhagic shock). Late RHF, at 3 months, was present in 13% patients. Medium non-invasive TAPSE/PASP ratio was 0,47 mm/mmHg, and showed good correlation with the invasive measurement (Pearson coefficient 0,758, p-value <0,001). TAPSE/PASP ratio showed a good predictive capacity for survival (area under the curve (AUC) = 0,65; 95% confidence interval (CI) 0,562-0,933; p-value=0,045). The other hemodynamic variables with good predictive capacity were the RA/PCWP ratio and PAPI -figure 1-. In the analysis of survival for death alone or combined death or RHF, the TAPSE/PASP ratio showed statistical significance for the threshold estimated by Youden index (TAPSE/PASP < 0,24 mm/mmHg) but not for the threshold defined in the literature (TAPSE/PASP < 0,33 mm/mmHg) -figure 2-. The non-invasive TAPSE/PASP ratio has not demonstrated to predict RHF in LVAD users, however, a low value before the implant could help to predict worse survival in this population. Other parameters with possible predictive value are RA/PCWP ratio and PAPI. Larger studies are required to test these hypothesesFigure 1 Figure 2