Right ventricular-pulmonary artery coupling in patients with tricuspid valve regurgitation: Use of echo-derived pulmonary artery effective elastance

Abstract Aims Tricuspid valve regurgitation (TR) is common and associated with increased mortality. The interaction between the pulmonary artery (PA) circulation and the right ventricle (RV) and association with outcomes is incompletely understood. The effective PA elastance (PA Ea) is a composite measure of RV afterload that refers to the pulmonary vascular load that the RV must overcome to eject blood. Whether PA Ea discriminates mortality risk in unselected patients with significant TR is unknown. Methods and Results In consecutive patients with ≥ moderate TR, we compared all-cause mortality at five years based on the PA Ea (defined as the RV systolic pressure/stroke volume as measured by transthoracic echocardiography). In a total of 12,682 patients, the median PA Ea was 0.7 mmHg/mL (IQR 0.5, 0.9). Increasing levels of PA Ea were associated with heart failure, liver and kidney disease and clinical markers of risk such as the TRIO score. Increasing levels of PA Ea were associated with larger RVs, worse RV systolic function, higher NT-pro BNP levels, and greater degrees of right heart failure. After adjusting for age and sex, PA Ea was associated with higher risk of death (HR 1.55 per 0.5 mmHg/mL change of PA EA; 95% confidence intervals 1.51-1.60); p<.0001). In multivariable modeling incorporating available clinical variables, PA Ea was independently predictive of outcome compared to other indexes of RV-PA coupling. Conclusion(s) In patients with significant TR, higher PA Ea is progressively associated with RV dysfunction, right heart failure, and worse survival. Incorporating PA Ea into the routine echo assessment may help stratify risk.