Right–ventricular Trajectories After Valve Surgery: Identifying a High–risk Uncoupling Phenotype and Its Impact on Early Outcomes

Background Right–ventricular (RV) dysfunction is frequent after valve surgery, but static postoperative measurements provide a limited understanding of RV adaptation. We aimed to characterise 6–month RV functional trajectories and assess their prognostic relevance, integrating RV–pulmonary arterial (PA) coupling with clinical outcomes. Methods Prospective single–centre study including 147 adults undergoing elective valve surgery (aortic, mitral or combined±tricuspid); isolated CABG was excluded. Echocardiography was performed at baseline, predischarge, 3 and 6 months. RV assessment included TAPSE, S’, RV free–wall longitudinal strain(RV–LS) and TAPSE/PASP (RV–PA coupling). Perioperative pharmacological management followed an institutional protocol and was included as covariates; intraoperative parameters (bypass and cross–clamp times) were recorded. Outcomes were prolonged mechanical ventilation, ICU stay, acute right–sided HF and 6–month HF readmissions. Longitudinal RV patterns were identified using latent trajectory modelling; predictors and outcomes were analysed with multivariable regression Result 3 trajectories were identified:(a) Rapid–recovery(34%):early TAPSE decline predischarge with recovery at 6 months, stable RV–LS and preserved coupling;(b)Delayed–recovery (26%): marked early impairment with partial improvement and transient TAPSE/PASP‹0.35; (c) Persistent–dysfunction (40%):sustained TAPSE≤13 mm and RV–LS≥−14% with RV–PA uncoupling (TAPSE/PASP≤0.30). Baseline pulmonary hypertension and pre–operative RV–LS impairment independently predicted allocation to the persistent–dysfunction trajectory (p‹0.01), whereas bypass and cross–clamp times were not independently associated with trajectories or outcomes. The persistent–dysfunction group showed higher rates of prolonged ventilation, acute right–sided HF, longer ICU stay and more 6–month HF readmissions (p≤0.02). Predischarge RV–PA uncoupling (TAPSE/PASP‹0.35) independently predicted HF readmission, offering incremental prognostic value over TAPSE Conclusion RV function after valve surgery does not follow a uniform postoperative course. 3 trajectory–based phenotypes were identified, and persistent RV dysfunction with RV–PA uncoupling defined a high–risk subgroup associated with early adverse outcomes. A trajectory–based assessment integrating TAPSE, RV–LS and TAPSE/PASP may enhance postoperative risk stratification and guide structured follow–up in vulnerable patients. This approach may help target closer clinical surveillance and follow–up strategies