Using TAPSE (tricuspid annular plane systolic excursion) as a predictor of poor prognosis of COVID-19: is it enough?

We have read with great interest the study by Martha et al. (Martha et al., 2021Martha J.W. Pranata R. Wibowo A. Lim M.A. Tricuspid annular plane systolic excursion (TAPSE) measured by echocardiography and mortality in COVID-19: a systematic review and meta-analysis.Int J Infect Dis. 2021; 105: 351-356https://doi.org/10.1016/j.ijid.2021.02.029Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar) recently published in the Journal, where the authors studied the association between the tricuspid annular plane systolic excursion (TAPSE) and mortality in patients with COVID-19. In their systemic review, the authors confirmed that TAPSE was lower in non-survivors than survivors and that each 1 mm decrease in TAPSE led to an increase in mortality of approximately 20%. These findings are undoubtedly of great practical importance. TAPSE reflects the longitudinal shortening of the right ventricle (RV) and is a simple and reproducible parameter of RV systolic function (Kaul et al., 1984Kaul S. Tei C. Hopkins J.M. Shah P.M. Assessment of right ventricular function using two-dimensional echocardiography.Am Heart J. 1984; 107: 526-531https://doi.org/10.1016/0002-8703(84)90095-4Crossref PubMed Scopus (816) Google Scholar). In severe COVID-19, the most important cause of RV dysfunction is pulmonary hypertension (PH) due to pulmonary endothelial injury (Varga et al., 2020Varga Z. Flammer A.J. Steiger P. Haberecker M. Andermatt R. Zinkernagel A.S. et al.Endothelial cell infection and endotheliitis in COVID-19.Lancet. 2020; 395: 1417-1418https://doi.org/10.1016/S0140-6736(20)30937-5Abstract Full Text Full Text PDF PubMed Scopus (4238) Google Scholar), widespread small pulmonary arteriolar thrombi (Ciceri et al., 2020Ciceri F. Beretta L. Scandroglio A.M. Colombo S. Landoni G. Ruggeri A. et al.Microvascular COVID-19 lung vessels obstructive thromboinflammatory syndrome (MicroCLOTS): an atypical acute respiratory distress syndrome working hypothesis.Crit Care Resusc. 2020; 22: 95-97PubMed Google Scholar) and hypoxic pulmonary vasoconstriction (Pagnesi et al., 2020Pagnesi M. Baldetti L. Beneduce A. Calvo F. Gramegna M. Pazzanese V. et al.Pulmonary hypertension and right ventricular involvement in hospitalised patients with COVID-19.Heart. 2020; 106: 1324-1331https://doi.org/10.1136/heartjnl-2020-317355Crossref PubMed Scopus (138) Google Scholar). On the other hand, severe systemic inflammation can cause myocardial injury (Santoso et al., 2020Santoso A. Pranata R. Wibowo A. Al-Farabi M.J. Huang I. Antariksa B. Cardiac injury is associated with mortality and critically ill pneumonia in COVID-19: a meta-analysis.Am J Emerg Med. 2020; (S0735-6757(20)30280-1. Epub ahead of print)https://doi.org/10.1016/j.ajem.2020.04.052Abstract Full Text Full Text PDF Scopus (104) Google Scholar), and the RV is particularly susceptible to SARS-CoV-2 infection (Szekely et al., 2020Szekely Y. Lichter Y. Taieb P. Banai A. Hochstadt A. Merdler I. et al.Spectrum of cardiac manifestations in COVID-19: a systematic echocardiographic study.Circulation. 2020; 142: 342-353https://doi.org/10.1161/CIRCULATIONAHA.120.047971Crossref PubMed Scopus (386) Google Scholar). Initially, with developing PH, RV responds to a significantly elevated afterload by increasing its contractility (homeometric response). This response may be accompanied by an increased TAPSE. However, with persistent and progressive PH, TAPSE may not correspond to an increase in pulmonary artery pressure (Tello et al., 2019Tello K. Wan J. Dalmer A. Vanderpool R. Ghofrani H.A. Naeije R. et al.Validation of the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio for the assessment of right ventricular-arterial coupling in severe pulmonary hypertension.Circ Cardiovasc Imaging. 2019; 12e009047https://doi.org/10.1161/CIRCIMAGING.119.009047Crossref PubMed Scopus (214) Google Scholar). In this case, even with a small increase in afterload, a decrease in the contractility of the RV may be observed, which may be accompanied by a decrease in TAPSE. Thus, in COVID-19, it is important to evaluate TAPSE and the ratio of TAPSE to pulmonary artery systolic pressure (PASP) (TAPSE/PASP). The indicator TAPSE/PASP is a valid surrogate for the assessment of RV-pulmonary arterial coupling (Tello et al., 2019Tello K. Wan J. Dalmer A. Vanderpool R. Ghofrani H.A. Naeije R. et al.Validation of the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio for the assessment of right ventricular-arterial coupling in severe pulmonary hypertension.Circ Cardiovasc Imaging. 2019; 12e009047https://doi.org/10.1161/CIRCIMAGING.119.009047Crossref PubMed Scopus (214) Google Scholar). Previous studies have revealed a high predictive value of this parameter in patients with heart failure and PH (Guazzi, 2018Guazzi M. Use of TAPSE/PASP ratio in pulmonary arterial hypertension: an easy shortcut in a congested road.Int J Cardiol. 2018; 266: 242-244https://doi.org/10.1016/j.ijcard.2018.04.053Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar). In a recent study, D’Alto et al. showed that the TAPSE/PASP ratio was an independent predictor of mortality of patients with COVID-19; moreover, the TAPSE/PASP ratio significantly added to the prognostic relevance of the PaO2/FiO2 ratio in these patients (D’Alto et al., 2020D’Alto M. Marra A.M. Severino S. Salzano A. Romeo E. De Rosa R. et al.Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS.Crit Care. 2020; 24: 1-10https://doi.org/10.1186/s13054-020-03385-5Crossref PubMed Scopus (62) Google Scholar). Given the multifaceted and complex pathways of pathogenesis in COVID-19, we believe that the determination of the TAPSE/PASP will improve the assessment of the prognosis of the disease. Further research is needed for systemic analysis. None.