Usefulness of ePLAR as a non-invasive predictor of adverse clinical events following transcatheter aortic valve implantation

Abstract Background The echocardiographic pulmonary to left atrial ratio (ePLAR) is a simple Doppler-derived parameter, calculated as the ratio between the maximum tricuspid regurgitation velocity (TRVmax) and the medial E/e’ ratio, that has proved to be helpful for differentiating precapillary from postcapillary pulmonary hypertension (PH). Our objective was to evaluate its prognostic value in patients with elevated pulmonary pressures undergoing transcatheter aortic valve implantation (TAVI). Methods A total of 1,456 patients who underwent TAVI at a single center between 2009-2023 were prospectively recruited. Of those, 277 patients with TRVmax 2.8 m/s were analyzed and stratified based on ePLAR values, following published thresholds: ePLAR 0.45 (representing postcapillary PH 0.2 or combined PH 0.2–0.45) and ePLAR ≥ 0.45 (indicative of precapillary PH). Associations between ePLAR and clinical/echocardiographic characteristics as well as post-procedural clinical events were evaluated. Results Among 277 patients, 160 (58%) were female. Mean age was 83.3 ± 5.9 years. A total of 239 patients had ePLAR 0.45 (149 with 0.2, and 90 with 0.2–0.45), while 38 had ePLAR ≥ 0.45. Age and sex distribution were comparable between groups. Patients with ePLAR 0.45 had a higher prevalence of cardiovascular risk factors, whereas those with ePLAR ≥ 0.45 more frequently had a history of chronic pulmonary disease. Regarding echocardiographic findings, patients with ePLAR ≥ 0.45 showed greater left ventricular dilatation and significantly higher rates of mitral and tricuspid regurgitation. No significant differences were observed in biventricular systolic function parameters (Table). Cardiovascular mortality was significantly higher among patients with ePLAR ≥ 0.45 (19% vs 7%; p = 0.028), and there was a non-significant trend toward increased heart failure hospitalizations in the same group (37% vs 24%, p = 0.077). Conclusions Our findings suggest that ePLAR, a simple and non-invasive echocardiographic parameter, may effectively identify TAVI patients with pulmonary hypertension at greater risk of adverse outcomes. It may serve as a valuable tool to guide patient selection and timing of intervention.