Association between right ventricular–arterial coupling assessed by TAPSE/PSAP and postoperative outcomes after cardiac surgery

Introduction Right ventricular function plays a central role in perioperative outcomes after cardiac surgery. Conventional parameters incompletely reflect right ventricular reserve because of complex geometry and load dependence. The tricuspid annular plane systolic excursion to pulmonary artery systolic pressure ratio (TAPSE/PSAP) integrates contractility and pulmonary afterload as a non-invasive measure of right ventricular–arterial coupling. Although it has shown prognostic value in heart failure and pulmonary hypertension, its role in open cardiac surgery remains unclear. Objective To determine whether reduced preoperative TAPSE/PSAP is associated with postoperative complications in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods This retrospective study included 593 adults undergoing cardiac surgery with cardiopulmonary bypass between June 2022 and December 2024 at a tertiary centre. Preoperative echocardiographic data were retrieved from institutional reports. TAPSE/PSAP was calculated and categorised according to the twenty-fifth percentile (≤0.32 defined as low). Outcomes included low cardiac output syndrome, postoperative atrial fibrillation, acute kidney injury, transfusion requirement, renal replacement therapy, major infections, intensive care unit stay, total hospital stay and in-hospital mortality. Early perfusion parameters and vasoactive and inotropic support within 24 hours were analysed. Multivariable logistic regression assessed independent associations. Results Overall, 24.3% had TAPSE/PSAP ≤0.32. These patients had worse preoperative status, higher surgical risk (European System for Cardiac Operative Risk Evaluation II (EuroSCORE II)) and longer operative times. A low ratio was associated with low cardiac output syndrome (27.1% vs 10.5%, p<0.001) and postoperative atrial fibrillation (22.2% vs 15.0%, p=0.043), as well as longer hospital stay (21.2 vs 17.4 days, p=0.025). Early after surgery, patients with a low ratio showed reduced arterial and venous oxygen content, lower oxygen delivery and greater need for vasoactive and inotropic support. In multivariable analysis, TAPSE/PSAP ≤0.32 independently predicted low cardiac output syndrome (odds ratio (OR) 3.18; 95% confidence interval (CI) 1.97–5.11; p<0.001) and postoperative atrial fibrillation (OR 1.62; 95% CI 1.01–2.60; p=0.045). Conclusions Impaired preoperative right ventricular–arterial coupling identifies patients with limited ability to adapt to surgical haemodynamic stress. TAPSE/PSAP ≤0.32 independently predicts clinically relevant postoperative complications, greater pharmacological support and prolonged hospital stay. Although in-hospital mortality did not differ, the higher morbidity supports incorporating right ventricular–arterial coupling assessment into preoperative risk stratification. Prospective studies should determine whether integrating this index into perioperative management improves outcomes.