Right Ventricular–Pulmonary Artery Coupling in Cardiac Resynchronization Therapy: Evolution and Prognosis

ESC Heart Failure, vol. 9, pp. 1597–1607

Abstract

AIMS: Chronic pressure overload and right ventricular (RV) dysfunction can lead to RV-pulmonary artery (PA) uncoupling in patients with heart failure. The evolution and prognostic values of RV-PA coupling assessed by echocardiography in patients undergoing cardiac resynchronization therapy (CRT) have not been thoroughly investigated. The aim of this study was to evaluate the evolution and prognostic value of tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) ratio in CRT recipients. METHODS AND RESULTS: The RV-PA coupling was measured non-invasively with echocardiography using the TAPSE/PASP ratio at baseline and 6 month follow-up in CRT recipients. The cut-off value for TAPSE/PASP uncoupling was derived from spline curve analysis (i.e. <0.45 mm/mmHg). The primary endpoint was all-cause mortality. A total of 807 patients (age 66 ± 11 years, 76% men) were analysed. During a median follow-up of 97 (54-143) months, 483 (60%) patients died. Survival rates at 3 and 5 year follow-up were significantly lower for patients with a TAPSE/PASP ratio <0.45 mm/mmHg (76% and 58%, respectively), compared with those with a TAPSE/PASP ratio ≥0.45 mm/mmHg (91% and 82%, respectively) (P < 0.001). On multivariable analysis, TAPSE/PASP ratio <0.45 mm/mmHg (hazard ratio 1.437; 95% confidence interval: 1.145-1.805; P = 0.002) was independently associated with all-cause mortality, whereas TAPSE <17 mm (hazard ratio 1.237; 95% confidence interval: 0.990-1.546; P = 0.061) was not. In addition, no improvement of the TAPSE/PASP ratio after CRT implantation was independently associated with worse survival. CONCLUSIONS: The TAPSE/PASP ratio at baseline is independently associated with long-term outcomes in CRT recipients. The baseline TAPSE/PASP ratio has incremental value over TAPSE, which does not take account of RV afterload. A lack of improvement in the TAPSE/PASP ratio after CRT implantation is associated with worse survival.

Authors 7

1. Jan Stassen Aachen Department of Cardiology, Heart and Lung Center

   Leiden University Medical Center · Jessa Hospital

   Affiliation as printed

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center , Albinusdreef 2, Leiden, 2300 RC ,

   Department of Cardiology, Jessa Hospital Hasselt , Hasselt ,

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC The Netherlands

   Department of Cardiology, Jessa Hospital Hasselt, Hasselt, Belgium

2. Xavier Galloo Aachen Department of Cardiology, Heart and Lung Center

   Vrije Universiteit Brussel · Leiden University Medical Center · Universitair Ziekenhuis Brussel

   Affiliation as printed

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center , Albinusdreef 2, Leiden, 2300 RC ,

   Department of Cardiology, Vrije Universiteit Brussel (VUB) and Universitair Ziekenhuis Brussel (UZ Brussel) , Brussels ,

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC The Netherlands

   Department of Cardiology, Vrije Universiteit Brussel (VUB) and Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium

3. Surenjav Chimed Aachen Department of Cardiology, Heart and Lung Center

   Leiden University Medical Center

   Affiliation as printed

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center , Albinusdreef 2, Leiden, 2300 RC ,

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC The Netherlands

4. Nina Ajmone Marsan Aachen Department of Cardiology, Heart and Lung Center

   Leiden University Medical Center

   Affiliation as printed

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center , Albinusdreef 2, Leiden, 2300 RC ,

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC The Netherlands

5. Victoria Delgado Aachen Department of Cardiology, Heart and Lung Center

   Leiden University Medical Center

   Affiliation as printed

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center , Albinusdreef 2, Leiden, 2300 RC ,

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC The Netherlands

6. Pieter van der Bijl Aachen Department of Cardiology, Heart and Lung Center

   Leiden University Medical Center

   Affiliation as printed

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center , Albinusdreef 2, Leiden, 2300 RC ,

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC The Netherlands

7. Jeroen Joost Bax corresponding Aachen Department of Cardiology, Heart and Lung Center

   University of Turku · Leiden University Medical Center · Turku University Hospital

   Affiliation as printed

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center , Albinusdreef 2, Leiden, 2300 RC ,

   Turku Heart Center, University of Turku and Turku University Hospital , Turku ,

   Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC The Netherlands

   Turku Heart Center, University of Turku and Turku University Hospital, Turku, Finland