Echo TAPSE/PAPs Identified Higher-Risk PH Before TAVR
Key Takeaways
- The paper reports pulmonary hypertension in 44% of its cohort on right heart catheterization, with 53% of those cases labeled combined pulmonary hypertension and 47% isolated post-capillary pulmonary hypertension.
- Lower echocardiographic TAPSE/PAPs appeared linked to the group labeled combined pulmonary hypertension in the paper’s group-comparison analyses.
- Echocardiographic and invasive TAPSE/PAPs were moderately correlated.
- An echocardiographic TAPSE/PAPs threshold of 0.29 mm/mmHg showed moderate discrimination for the group labeled combined pulmonary hypertension and separated 2-year mortality curves.
In the Putortì et al. study of eTAPSE/PAPs, pulmonary hypertension subtype, and mortality in TAVR, the paper describes 667 patients treated from 2015 to 2022, but it also lists exclusions including procedures after December 2019 despite a 2-year endpoint; the exact post-exclusion analytic sample is not clear from the published text. The published report states that included patients underwent preprocedural TTE and right heart catheterization (RHC), and 2-year all-cause mortality was the primary endpoint. TAPSE was used as a surrogate of right ventricular systolic function, systolic pulmonary artery pressure on echocardiography was estimated from the tricuspid regurgitation jet plus estimated right atrial pressure, and invasive phenotyping was assigned by RHC using the authors' reported European Society of Cardiology/European Respiratory Society pulmonary hypertension cutoffs. After exclusion of valve-in-valve procedures, incomplete RHC data, patients without the prespecified follow-up window, unsuccessful TAVR by Valve Academic Research Consortium-3 technical success criteria, incomplete preprocedural TTE, and pre-capillary pulmonary hypertension, patients were grouped as no pulmonary hypertension, isolated post-capillary pulmonary hypertension, or a group labeled combined pulmonary hypertension.
Using the paper’s reported RHC subgrouping, pulmonary hypertension was reported in nearly half the cohort described in the paper, with the group labeled combined pulmonary hypertension slightly more common than isolated post-capillary disease among affected patients. Echocardiographic and invasive TAPSE/PAPs were moderately correlated, with Spearman's rho 0.54 and p < 0.001. In the paper’s group-comparison analyses, patients in the group labeled combined pulmonary hypertension had higher invasive pulmonary pressures and pulmonary vascular resistance, together with lower echocardiographic and invasive TAPSE/PAPs ratios, than the other hemodynamic groups.
Echocardiographic TAPSE/PAPs discriminated the group labeled combined pulmonary hypertension with an AUC of 0.740, and the reported optimal cutoff was 0.29 mm/mmHg with 72% sensitivity and 60% specificity. During follow-up, 157 deaths were recorded, and 2-year overall mortality differed when patients were stratified by that cutoff, with log-rank 4.94 and p = 0.026. The authors also reported that echocardiographic TAPSE/PAPs remained independently associated with all-cause mortality in multivariable analysis.
The analysis was retrospective, observational, non-randomized, and single-center, so it does not establish causality. The authors also noted that no follow-up TTE or RHC data were available, that the cohort consisted predominantly of patients with high-gradient aortic stenosis, and that relatively few patients had reduced TAPSE, which may affect how broadly the reported cutoff applies. In that context, the ratio is best read as a noninvasive marker associated with a higher-risk hemodynamic phenotype before TAVR rather than as a replacement for invasive hemodynamic assessment. Because the cohort came from a European center, the findings describe that practice setting rather than directly mapping to North American care pathways.
The investigators reported that, in patients undergoing TAVR for severe symptomatic aortic stenosis, a lower echocardiographic TAPSE/PAPs ratio was associated in group-comparison analyses with the invasively assigned group labeled combined pulmonary hypertension and with poorer 2-year survival stratification.
Clinician Questions
How was combined pulmonary hypertension defined before TAVR in this cohort?
Combined pulmonary hypertension was defined with the reported 2022 ESC/ERS invasive cutoffs as mean pulmonary artery pressure greater than 20 mmHg, pulmonary vascular resistance greater than 2 WU, and the pulmonary capillary wedge pressure criterion reported in the article. Isolated post-capillary pulmonary hypertension used the same mean pulmonary artery pressure threshold with pulmonary vascular resistance below 2 WU and pulmonary capillary wedge pressure above 15 mmHg, and pre-capillary pulmonary hypertension cases were excluded from the analysis.
Which patients were excluded from the RV-PA uncoupling analysis before TAVR?
The analysis excluded valve-in-valve procedures, incomplete right heart catheterization data, patients whose projected follow-up would have been shorter than 3 years because the procedure occurred after December 2019, unsuccessful TAVR implantation by VARC-3 technical success criteria, incomplete preprocedural transthoracic echocardiography, and pre-capillary pulmonary hypertension.
What limits how broadly the 0.29 mm/mmHg eTAPSE/PAPs cutoff applies in severe aortic stenosis?
Its applicability is limited by the retrospective, single-center, non-randomized design, the predominance of high-gradient aortic stenosis in the cohort, the small number of patients with reduced TAPSE, and the absence of follow-up echocardiographic or right heart catheterization data; the authors said the cutoff needs further refinement in broader populations.