Right Ventricular-Pulmonary Arterial Coupling and Afterload Reserve in Patients Undergoing Transcatheter Tricuspid Valve Repair
Michael I. BrenerPhilipp LurzJörg HausleiterJosep Rodés‐CabauNeil FamSusheel KodaliKarl‐Philipp RommelGuillem Muntané‐CarolMara GavazzoniTamim NazifAlberto PozzoliHannes AlessandriniAzeem LatibLuigi BiascoDaniel BraunÉric BrochetPaolo DentiEdith LubosSebastian LudwigDaniel KalbacherRodrigo Estévez‐LoureiroKim A. ConnellyChristian FrerkerEdwin HoJean‐Michel JuliardClaudia HarrVanessa MoñivasGeorg NickenigGiovanni PedrazziniFrançois PhilipponFabien PrazRishi PuriJoachim SchöferHorst SievertGilbert H.L. TangMartin AndreasHölger ThieleMatthias UnterhuberDominique HimbertRalph Stephan von BardelebenStephan WindeckerMirjam G. WildFrancesco MaisanoMartin B. LeonMaurizio TaramassoRebecca T. Hahn
Why the study?
The prognostic significance of right ventricular-pulmonary arterial coupling in patients with tricuspid regurgitation undergoing transcatheter tricuspid valve repair or replacement was unknown.
Does a higher RV-PA coupling ratio (TAPSE/PASP >0.406) predict lower all-cause mortality in patients with tricuspid regurgitation undergoing transcatheter tricuspid valve repair?
Study Design
Type
Cohort (n=444)
Multicenter
Yes
Structured PICO
Does a higher RV-PA coupling ratio (TAPSE/PASP >0.406) predict lower all-cause mortality in patients with tricuspid regurgitation undergoing transcatheter tricuspid valve repair?
P
Population
444 patients (mean age 76.9 years, 53.8% female) with tricuspid regurgitation undergoing transcatheter tricuspid valve repair or replacement, followed for 1 year.
E
Exposure
Right ventricular-pulmonary arterial (RV-PA) coupling ratio (TAPSE/PASP) >0.406 mm/mm Hg
C
Comparator
TAPSE/PASP ratio ≤0.406 mm/mm Hg
O
Outcome
All-cause mortality at 1-year follow-uphard clinical
Main Result
Hazard Ratio: 0.57 (95% CI 0.35–0.93)
Absolute Event Rate: 9.5% vs 18.9%
p-value: p=0.023
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Between the two commercially available options that we have now—valve repair and replacement—we need to refine how we choose the treatment for each patient. We need to identify which patients would do better with a valve replacement, because that strategy isn't a good fit for everybody.”
Implication
In patients undergoing transcatheter tricuspid valve repair, a baseline TAPSE/PASP ratio >0.406 is an independent predictor of reduced 1-year all-cause mortality.
Abstract
BACKGROUND The right ventricular (RV)-pulmonary arterial (PA) coupling ratio relates the efficiency with which RV stroke work is transferred into the PA. Lower ratios indicate an inadequate RV contractile response to increased afterload. OBJECTIVES This study sought to evaluate the prognostic significance of RV-PA coupling in patients with tricuspid regurgitation (TR) who were undergoing transcatheter tricuspid valve repair or replacement (TTVR). METHODS The study investigators calculated RV-PA coupling ratios for patients enrolled in the global TriValve registry by dividing the tricuspid annular plane systolic excursion (TAPSE) by the PA systolic pressure (PASP) from transthoracic echocardiograms performed before the procedure and 30 days after the procedure. The primary endpoint was all-cause mortality at 1-year follow-up. RESULTS Among 444 patients analyzed, their mean age was 76.9 ± 9.1 years, and 53.8% of the patients were female. The median TAPSE/PASP ratio was 0.406 mm/mm Hg (interquartile range: 0.308-0.567 mm/mm Hg). Sixty-three patients died within 1 year of TTVR, 21 with a TAPSE/PASP ratio >0.406 and 42 with a TAPSE/PASP ratio ≤0.406. In multivariable Cox regression analysis, a TAPSE/PASP ratio >0.406 vs ≤0.406 was associated with a decreased risk of all-cause mortality (HR: 0.57; 95% CI: 0.35-0.93; P = 0.023). In 234 (52.7%) patients with echocardiograms 30 days after TTVR, a decline in RV-PA coupling was independently associated with reduced odds of all-cause mortality (odds ratio [OR]: 0.42; 95% CI: 0.19-0.93; P = 0.032). The magnitude of TR reduction after TTVR (≥1+ vs <1+; OR: 2.53; 95% CI: 1.06-6.03; P = 0.037) was independently associated with a reduction in post-TTVR RV-PA coupling. CONCLUSIONS RV-PA coupling is a powerful, independent predictor of all-cause mortality in patients with TR undergoing TTVR. These data suggest that the TAPSE/PASP ratio can inform patient selection and prognostication following TTVR.
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Cite This Study
Brener et al. (2022) conducted a cohort in Tricuspid regurgitation (n=444). TAPSE/PASP ratio >0.406 vs. TAPSE/PASP ratio ≤0.406 was evaluated on All-cause mortality at 1-year follow-up (HR 0.57, 95% CI 0.35-0.93, p=0.023).