Clinical Investigation
Significance of RV-PA Coupling in Transcatheter Mitral Repair
Prognostic Value of Baseline Tricuspid Annular Plane Systolic Excursion to Pulmonary Artery Systolic Pressure Ratio in Mitral Transcatheter Edge-to-Edge Repair

https://doi.org/10.1016/j.echo.2022.12.026Get rights and content

Highlights

  • The TAPSE/PASP ratio is a widely available surrogate of RV-PA coupling.

  • In our 707-patient mitral TEER registry, its median value was 37 mm/mm Hg.

  • Low TAPSE/PASP identified higher risk cases less likely to achieve technical success.

  • Also, it independently predicted the composite of mortality or HF hospitalizations.

  • The prognostic significance of TAPSE/PASP was confined to functional MR patients.

Background

A surrogate of right ventricular–pulmonary arterial coupling, the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) has been associated with outcomes across a wide range of cardiac pathologies and interventions. The aim of this study was to assess the prognostic significance of baseline TAPSE/PASP ratio in patients undergoing mitral transcatheter edge-to-edge repair.

Methods

This was a single-center, retrospective analysis encompassing 448 days (interquartile range, 86-958 days) of follow-up after 707 consecutive isolated, first-time mitral transcatheter edge-to-edge repair procedures. Stratified by the cohort’s median TAPSE/PASP ratio of 0.37 mm/mm Hg, eligible cases were examined for the occurrence of all-cause mortality and heart failure hospitalization.

Results

Patients with low TAPSE/PASP ratios exhibited a greater prevalence of functional mitral regurgitation, a higher burden of comorbidities, and worse clinical and echocardiographic indices of cardiac function, as well as an attenuated rate of technical success. After the procedure, they experienced similar 1-month and 1-year improvement in mitral regurgitation grade and functional status but higher rates of death, heart failure hospitalizations, and the composite of both at all time points explored (1 year, 15.3% vs 7.6%, 20.7% vs 10.2%, and 32.3% vs 16.1%, respectively; P < .001 for all). Lower TAPSE/PASP ratio was independently associated with a higher risk for the 1-year combined end point of death or heart failure hospitalizations (hazard ratio, 2.84; 95% CI, 1.09-7.43; P = .033). A novel TAPSE/PASP-MitraScore risk model showed a better discriminative property than currently validated scores. Subgroup analysis produced similarly significant observations solely in patients with functional mitral regurgitation (n = 383 [54.2%]), which remained when using subgroup-specific medians of the baseline TAPSE/PASP ratio.

Conclusions

A low TAPSE/PASP ratio before mitral transcatheter edge-to-edge repair identifies higher risk patients and predicts a less favorable outcome after the procedure.

Section snippets

Study Population and Outcomes

Our study is based on the Cedars-Sinai Medical Center registry of consecutive mitral TEER procedures performed during the time frame of January 1, 2013, through December 31, 2020. The registry was retrospectively constructed using CS-Link (Epic), a web-based patient medical records platform that contains data regarding demographic characteristics, medical conditions and therapeutics, electrocardiographic tracings, laboratory and imaging results, procedural details, and outcome measures and

Baseline Characteristics of the Study Population

Among 1,055 patients included in the Cedars-Sinai Medical Center registry, 707 underwent isolated, first-time mitral TEER and had data on baseline TAPSE/PASP ratio, the median of which was 0.37 mm/mm Hg (IQR, 0.27-0.55 mm/mm Hg). These patients were followed for a median duration of 448 days (IQR, 86-958 days). Baseline and 1-month echocardiograms were obtained at a median of 16 days (IQR, 5-44 days) before and 33 days (IQR, 28-36 days) after the procedure, respectively.

Compared with the

Discussion

Our study is among the largest, most comprehensive ones to examine the prognostic implications of baseline TAPSE/PASP ratio in real-world mitral TEER patients. Using 0.37 mm/mm Hg as a cutoff value, we found a constellation of worse preprocedural status, intraprocedural hemodynamic effects, and immediate postprocedural results in those with low ratios, who eventually experienced earlier, more frequent deaths and HF hospitalizations at 1 year and along the entire follow-up period.

Conclusion

A low TAPSE/PASP ratio before mitral TEER signifies a higher risk patient profile and, in the case of functional MR, is associated with excessive postprocedural mortality and HF hospitalizations. Further research is needed to reveal the pathways underlying these observations and to assess the clinical implication of incorporating this echocardiographic parameter in the patient selection process.

References (24)

Cited by (5)

This study was supported in part by the California Chapter of the American College of Cardiology through the Save a Heart Foundation.

Dr. Makkar has received grant support from Edwards Lifesciences; is a consultant for Abbott Vascular, Cordis, and Medtronic; and holds equity in Entourage Medical. Dr. Chakravarty is a consultant, proctor, and speaker for Edwards Lifesciences and Medtronic; is a consultant for Abbott; and is a consultant and speaker for Boston Scientific.

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