Right ventricular-pulmonary artery coupling for prognostication in acute pulmonary embolism
Authors: Lyhne Mads Dam , Bikdeli Behnood , Jiménez David , Kabrhel Christopher , Dudzinski David M , Moisés Jorge , Lobo José Luis , Armestar Fernando , Guirado Leticia , Ballaz Aitor , Monreal Manuel ,   the RIETE investigators, Prandoni Paolo , Brenner Benjamin , Farge-Bancel Dominique , Barba Raquel , Di Micco Pierpaolo , Bertoletti Laurent , Schellong Sebastian , Tzoran Inna , Reis Abilio , Bosevski Marijan , Bounameaux Henri , Malý Radovan , Verhamme Peter , Caprini Joseph A , My Bui Hanh , Aibar J , Alberich-Conesa A , Alda-Lozano A , Alfonso J , Alonso-Carrillo J , Amado C , Angelina-García M , Arcelus J I , Ballaz A , Barba R , Barbagelata C , Barreiro B , Barrón M , Barrón-Andrés B , Bascuñana J , Beddar-Chaib F , Blanco-Molina A , Caballero J C , Cañas I , Carrero-Arribas R , Castellanos G , Chasco L , Claver G , Criado J , De Juana-Izquierdo C , Del Toro J , Demelo-Rodríguez P , Díaz-Pedroche M C , Díaz-Peromingo J A , Dubois-Silva A , Escribano J C , Falgá C , Fernández-Aracil C , Fernández-Capitán C , Fernández-Jiménez B , Fernández-Reyes J L , Fidalgo M A , Francisco I , Gabara C , Galeano-Valle F , García-Bragado F , García-Ortega A , Gavín-Sebastián O , Gil-Díaz A , Gómez-Cuervo C , González-Munera A , Grau E , Guirado L , Gutiérrez-Guisado J , Hernández-Blasco L , Hernández-Vidal M J , Jara-Palomares L , Jiménez D , Jou I , Joya M D , Lecumberri R , Llamas P , Lobo J L , López-Brull H , López-De la Fuente M , López-Jiménez L , López-Miguel P , López-Núñez J J , López-Ruiz A , López-Sáez J B , Lorente M A , Lorenzo A , Lumbierres M , Madridano O , Maestre A , Marchena P J , Marcos M , Martín del Pozo M , Martín-Martos F , Martínez-Prado R , Maza J M , Mercado M I , Moisés J , Molino A , Monreal M , Monzón L , Morales M V , Muñoz-Gamito G , Navas M S , Nieto J A , Núñez-Fernández M J , Olid M , Ordieres-Ortega L , Ortiz M , Osorio J , Otálora S , Otero R , Pacheco-Gómez N , Pagán J , Palomeque A C , Paredes E , Pedrajas J M , Pérez-Ductor C , Pérez-Pinar M , Peris M L , Pesce M L , Porras J A , Puchades R , Rivas A , Rivera-Cívico F , Rivera-Gallego A , Rodríguez-Cobo A , Romero-Bruguera M , Ruiz-Artacho P , Salgueiro G , Sánchez-Serrano M , Sancho T , Sendín V , Sigüenza P , Soler S , Steinherr A , Suárez-Fernández S , Tirado R , Torrents-Vilar A , Torres M I , Trujillo-Santos J , Uresandi F , Valle R , Varona J F , Villalobos A , Villares P , Ay C , Nopp S , Pabinger I , Vanassche T , Verhamme P , Verstraete A , Yoo H H B , Montenegro A C , Morales S N , Roa J , Hirmerova J , Malý R , Bertoletti L , Bura-Riviere A , Catella J , Chopard R , Couturaud F , Espitia O , Le Mao R , Leclerq B , Mahé I , Moustafa F , Plaisance L , Sarlon-Bartoli G , Suchon P , Versini E , Schellong S , Rashidi F , Sadeghipour P , Brenner B , Dally N , Kenet G , Tzoran I , Abenante A , Barillari G , Basaglia M , Bilora F , Bissacco D , Brandolin B , Casana R , Ciammaichella M , Dentali F , Di Micco P , Giorgi-Pierfranceschi M , Imbalzano E , Lambertenghi-Deliliers D , Marcon C , Martini R , Negro F , Poz A , Prandoni P , Simioni P , Siniscalchi C , Taflaj B , Tufano A , Visonà A , Zalunardo B , Kaulins R , Skride A , Tazi-Mezalek Z , Fonseca S , Marques R , Meireles J , Pinto S , Bosevski M , Stankovski T , Zdraveska M , Bounameaux H , Mazzolai L , Aujayeb A , Bikdeli B , Caprini J A , Khalil A , Tafur J , Weinberg I , Bui H M , Nguyen S T , Pham K Q , Tran G B 
Published: October 2024

Abstract

Aims
Acute pulmonary embolism (PE) increases pulmonary pressure and impair right ventricular (RV) function. Echocardiographic investigation can quantify this mismatch as the tricuspid annular plane systolic excursion (TAPSE) to pulmonary arterial systolic pressure (PASP) ratio. The aim of the study was to investigate the prognostic capabilities of TAPSE/PASP ratio in patients with acute PE.

Methods and results
We utilized the Registro Informatizado Enfermedad TromboEmbolica registry to analyse consecutive haemodynamically stable PE patients. We used multi-variable logistic regression analyses to assess the association between the TAPSE/PASP ratio and 30-day all-cause mortality across the strata of European Society of Cardiology (ESC) risk categories. We included 4478 patients, of whom 1326 (30%) had low-risk, 2425 (54%) intermediate-low risk and 727 (16%) intermediate-high risk PE. Thirty-day mortality rates were 0.7%, 2.3% and 3.4%, respectively. Mean TAPSE/PASP ratio was 0.65 ± 0.29 in low-risk patients, 0.46 ± 0.30 in intermediate-low risk and 0.33 ± 0.19 in intermediate-high risk patients. In multi-variable analyses, there was an inverse association between TAPSE/PASP ratio and 30-day mortality (adjusted OR 1.32 [95% CI 1.14–1.52] per 0.1 decrease in TAPSE/PASP). TAPSE/PASP ratio below optimal cut-points was associated with increased mortality in low- (&lt;0.40, aOR: 5.88; 95% CI: 1.63–21.2), intermediate-low (&lt;0.43, aOR: 2.96; 95% CI: 1.54–5.71) and intermediate-high risk patients (&lt;0.34, aOR: 4.37; 95% CI: 1.27–15.0). TAPSE/PASP &lt;0.44 showed net reclassification improvement of 18.2% (95% CI: 0.61–35.8) vs. RV/LV ratio &gt;1, and 27.7% (95% CI: 10.2–45.1) vs. ESC risk strata.

Conclusion
Decreased TAPSE/PASP ratio was associated with increased mortality. The ratio may aid in clinical decision-making, particularly for intermediate-risk patients for whom the discriminatory capability of the current risk stratification tools is limited.