TAVR has long been an effective strategy to treat aortic stenosis. However, ventricular damage starts further before symptom onset, also affecting the left ventricle, pulmonary vessels, the right ventricle, the tricuspid valve, and the right atrium.
It increases arterial afterload and uncouples the right ventricle and the pulmonary artery, defined by transthoracic echocardiogram as the relationship between the tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP), TAPSE/PSAP.
A reduction in this relationship (≤0.55 mmHg) is associated with unfavorable evolution.
The study looked at PARTNER 3 patients. 222 of these patients (38.9%) presented RV-PA uncoupling TAPSE/PSAP ≤0.55 mmHg; and 348, RV-PA coupling TAPSE/PSAP >0.55 mmHg.
Primary end point was a composite of all cause death, stroke and rehospitalization at 2 years.
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The populations were similar, mean age was 74, 66% were men, 30% were diabetic. Those presenting uncoupling had more arrythmia and higher BMP.
After two years, primary end point was higher among those presenting uncoupling (19.1% vs 9.9%; HR: 2.03; 95% CI: 1.29-3.19; P=0.002), as was all cause (5.9% vs 0.6%; P < 0.001), and cardiovascular mortality (4.1% vs 0.6%; P=0.003) and rehospitalization (13.5% vs 7.3% P=0.02). Stroke rate (24.2% vs 14.2%; HR: 1.83; 95% CI: 0.98-3.41; P ¼ 0.053ke) was fairly low, with no difference.
Uncoupled patients undergoing transcatheter aortic valve replacement had a higher incidence of primary end point (24.2% vs 14.2% P=0.05).
At multivariable analysis, uncoupling resulted an independent predictor of primary end point at 2 years.
Conclusion
In low risk symptomatic aortic stenosis patients undergoing TAVR or SAVR, baseline right ventricle and pulmonary artery uncoupling, defined as TAPSE/PSAP ≤0.55 mmHg, was associated to clinical adverse events at 2 years, including all cause and cardiovascular mortality, and rehospitalization.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Impact of Right Ventricle-Pulmonary Artery Coupling on Clinical Outcomes in the PARTNER 3 Trial.
Reference: Thomas J. Cahill, et al. J Am Coll Cardiol Intv 2022;15:1823–1833.
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