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

Abstract

Background: The ratios of tricuspid annular plane systolic excursion (TAPSE)/echocardiographically measured systolic pulmonary artery pressure (PASP), fractional area change/invasively measured mean pulmonary artery pressure, right ventricular (RV) area change/end-systolic area, TAPSE/pulmonary artery acceleration time, and stroke volume/end-systolic area have been proposed as surrogates of RV-arterial coupling. The relationship of these surrogates with the gold standard measure of RV-arterial coupling (invasive pressure-volume loop-derived end-systolic/arterial elastance [Ees/Ea] ratio) and RV diastolic stiffness (end-diastolic elastance) in pulmonary hypertension remains incompletely understood. We evaluated the relationship of these surrogates with invasive pressure-volume loop-derived Ees/Ea and end-diastolic elastance in pulmonary hypertension. Methods: We performed right heart echocardiography and cardiac magnetic resonance imaging 1 day before invasive measurement of pulmonary hemodynamics and single-beat RV pressure-volume loops in 52 patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension. The relationships of the proposed surrogates with Ees/Ea and end-diastolic elastance were evaluated by Spearman correlation, multivariate logistic regression, and receiver operating characteristic analyses. Associations with prognosis were evaluated by Kaplan-Meier analysis. Results: TAPSE/PASP, fractional area change/mean pulmonary artery pressure, RV area change/end-systolic area, and stroke volume/end-systolic area but not TAPSE/pulmonary artery acceleration time were correlated with Ees/Ea and end-diastolic elastance. Of the surrogates, only TAPSE/PASP emerged as an independent predictor of Ees/Ea (multivariate odds ratio: 18.6; 95% CI, 0.8–96.1; P =0.08). In receiver operating characteristic analysis, a TAPSE/PASP cutoff of 0.31 mm/mm Hg (sensitivity: 87.5% and specificity: 75.9%) discriminated RV-arterial uncoupling (Ees/Ea <0.805). Patients with TAPSE/PASP <0.31 mm/mm Hg had a significantly worse prognosis than those with higher TAPSE/PASP. Conclusions: Echocardiographically determined TAPSE/PASP is a straightforward noninvasive measure of RV-arterial coupling and is affected by RV diastolic stiffness in severe pulmonary hypertension. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03403868.

Right Ventricular-Arterial Uncoupling Independently Predicts Survival in COVID-19 ARDS

“…In these studies, the TAPSE/PASP was assumed to inform about RV-PA coupling, with TAPSE considered as a load-dependent surrogate of Ees and PASP as an indirect estimate of Ea (21)(22)(23). The TAPSE/PASP has been shown to be superior to other composite echocardiographic indices in the assessment of RV-PA and correlated to gold standard invasive (11) or indirectly assessed Ees/Ea ratios. (21).…”

“…We therefore assessed the coupling of RV function to the pulmonary circulation in COVID-19 ARDS patients. To this purpose, we used bedside trans-thoracic echocardiography with focus on the tricuspid annular plane systolic excursion (TAPSE) / pulmonary artery systolic pressure (PASP) ratio, previously shown to be a valid surrogate of the gold standard ratio of end-systolic to arterial elastance (Ees/Ea) for the assessment of RV-arterial coupling (11) and an independent predictor of outcome in heart failure and pulmonary arterial hypertension (12).…”

Effects of Sacubitril/Valsartan on the Right Ventricular Arterial Coupling in Patients with Heart Failure with Reduced Ejection Fraction

“…RV-pulmonary artery (RV-PA) coupling, an index of the in vivo RV length vs. developed force, and a non-invasive assay of the RV contractile state [ 11 ] have been proposed as early markers of RV ventricular dysfunction [ 12 ]. Recently, the tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) ratio has been proposed as the best echocardiographic method to evaluate it [ 13 ]. In patients with HFrEF, the effects of sacubitril/valsartan therapy on RV-PA coupling remain unknown; thus, we aimed to analyse the effect of sacubitril/valsartan on the TAPSE/PASP ratio in this patient group.…”

Right Ventricular Dysfunction Staging System for Mortality Risk Stratification in Heart Failure with Preserved Ejection Fraction

“…However, the TAPSE/PASP ratio has been shown to have an excellent correlation with invasive PA compliance, distributing along the exponential relationship between PA compliance and pulmonary circulation resistance [10,11], and showing an optimal correlation with the pre-capillary component of PH in HFpEF [20]. This index is a strong predictor of mortality and rehospitalizations in HFpEF beyond its components in isolation [8,10,11,20,21], and its value has been expanded to other conditions beyond HF, such as arterial PH or severe aortic stenosis [22,23]. However, for a global assessment of the RVD severity, it seems mandatory to evaluate the competency of the tricuspid valve, which should no longer be considered as an epiphenomenon.…”