Predicting Combined Pulmonary Hypertension in patients undergoing TAVR through TAPSE/PAPs as an index of RV-PA Uncoupling

Background: Right ventricular-pulmonary artery (RV-PA) uncoupling, expressed as the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (TAPSE/PAPs) ratio, is a negative prognostic indicator in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). Aim of the study: This study aims to explore the association between echocardiographically measured TAPSE/PAPs ratio and invasively determined pulmonary hypertension (PH) subtypes, especially Combined PH (CoPH), in order to determine which patients need right heart catheterization (RHC) before intervention and to assess the impact of RV-PA uncoupling on outcome in patients undergoing TAVR. Methods: This study is a retrospective analysis of 667 patients who underwent TAVR for native severe symptomatic AS at our center between January 2015 and December 2022. All patients underwent a comprehensive transthoracic echocardiographic evaluation and right heart catheterization prior to the procedure. PH was classified into: (1) no PH, (2) pre-capillary PH (PrcPH), (3) isolated post-capillary PH (IpcPH), and (4) CoPH. Follow-up time was defined as the time from the procedure to the last documented contact with the patient (alive) or to the time of documented death. All-cause mortality at two years was the primary endpoint. Results: eTAPSE/PAPs showed a moderate correlation with pulmonary vascular resistance (Spearman’s Rho = - 0.55; p = 0.025) and was associated with CoPH (odds ratio 1.29, 95% confidence interval 1.10 - 1.30). ROC curve analysis showed that eTAPSE/PAPs discriminated presence of CoPH with an AUC of 0.740. The optimal cut-off value was 0.29 mm/mmHg (sensitivity 72%, specificity 60%). During follow-up, 157 deaths were recorded. Kaplan-Meier curves showed a significant difference in overall mortality at 2 years when patients were stratified according to eTAPSE/PAPs ratio value of 0.29 (log rank = 4.94, p = 0.026). Conclusions: The eTAPSE/PAPs ratio identifies patients with symptomatic AS undergoing TAVR with higher risk of CoPH. These patients can benefit from an RHC to refine pre-operative risk assessment.