Page 120 - Advanced echocardiography in characterization and management of patients with secondary mitral regurgitation

Chapter six. Right ventricular - pulmonary artery coupling
Abstract
Background
Right ventricular (RV) dysfunction and pulmonary artery systolic pressure (PASP) are predictors of outcome in patients with secondary mitral regurgitation (MR). The right heart and the pulmonary circulation are however, interdependent and the relationship between RV contractility and afterload known as RV-PA coupling, can be estimated non-invasively. Accordingly, the purpose of this study is to investigate the incremental prognostic value of the ratio of tricuspid annular plane systolic excursion (TAPSE) and PASP (TAPSE/PASP) in patients with significant secondary MR.
Methods
A total of 591 patients (mean age 66±11 years, 67% male) with symptomatic secondary MR were included. The ratio TAPSE/PASP was measured and its association with the primary endpoint (all-cause mortality) was assessed.
Results
Based on spline curve analysis, a TAPSE/PASP ratio <0.35 was associated with an excess mortality. The patient population was divided into two groups: 229 (39%) patients with TAPSE/PASP<0.35 (impaired RV-PA coupling) and 362 (61%) with TAPSE/PASP≥0.35 (preserved RV-PA coupling). During a median follow-up of 54 [28, 105] months, 295 (50%) patients died. Patients with a TAPSE/PASP≥0.35 showed significantly better survival rates at 5-year follow-up than those with a TAPSE/PASP<0.35 (68% vs 53%, respectively, P= 0.001). On multivariable analysis, a TAPSE/PASP<0.35 remained independently associated with all-cause mortality (HR 1.283, 95% CI 1.008-1.633, P= 0.043).
Conclusions
In heart failure patients with secondary MR, TAPSE/PASP is independently associated with all-cause mortality and has an incremental prognostic value over TAPSE. By taking into account TAPSE/PASP ratio (as a measure for RV-PA coupling), it may improve further risk stratification of patients with secondary MR.
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