Page 126 - Advanced echocardiography in characterization and management of patients with secondary mitral regurgitation
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Chapter six. Right ventricular - pulmonary artery coupling
represents the 95% confidence interval range for each hazard ratio. The vertical dotted line representing the cut-off value TAPSE/PASP 0.35. PASP = pulmonary artery systolic pressure; TAPSE = tricuspid annular plane systolic excursion.
Survival analysis
During a median follow-up of 54 [28, 105] months, 295 patients (49.9%) died. Based on spline curve analysis, a threshold of TAPSE/PASP ratio <0.35 was associated with an excess risk of all-cause death (Figure 1). The assumption of linearity was not violated (χ2: 4.236, P= 0.13). This cut-off value was used to identify the patients with more RV- PA uncoupling.
Tables 1 and 2 show the baseline clinical and echocardiographic characteristics for patients with more impaired RV-PA uncoupling (n=229 [38.7%] TAPSE/PASP ratio <0.35) vs. those with more preserved RV-PA coupling (n=362 [61.3%] TAPSE/PASP ≥0.35). Patients with a TAPSE/PASP <0.35 were slightly older, were more frequently male, had a higher prevalence of atrial fibrillation and more impaired renal function compared to patients with a TAPSE/PASP ≥0.35. Patients with a TAPSE/PASP <0.35 were more symptomatic and were more frequently using diuretics compared to those with a TAPSE/PASP ≥0.35.
In terms of echocardiographic characteristics, patients with a TAPSE/PASP ≥0.35 had less impaired LV systolic function assessed by LV GLS. However, there were no significant differences in LV volumes and LVEF, E/e’ ratio or MR severity. Patients with a TAPSE/PASP <0.35 had a larger left atrial volume index compared to those with a TAPSE/PASP ≥0.35.
Survival analysis censored for occurrence of mitral valve intervention showed that patients with a TAPSE/PASP ≥0.35 had better survival rates as compared to patients with a TAPSE/PASP <0.35 (5-year estimated survival rates 81.1% vs. 66.7% respectively, P=0.002; Figure 2, panel A). Patients with a TAPSE/PASP ≥0.35 also had better survival rates than those with a TAPSE/PASP<0.35 when all patient follow-up data was analyzed, including after the performance of mitral valve intervention (5-year estimated survival rates 68.3% vs. 52.6% respectively, P=0.001; Figure 2, panel B). After correcting for age, male sex, impaired renal function, diabetes mellitus, ischemic aetiology, the use of diuretics, LV GLS and the performance of mitral valve intervention, by Cox proportional hazards modelling a TAPSE/PASP <0.35 was independently associated with all-cause mortality (HR 1.28, 95% CI 1.01-1.63, P=0.04) (Table 3).
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