Right ventricle-arterial coupling as a prognostic factor in patients with severe aortic stenosis who underwent surgical aortic valve replacement
Authors: Arias Godinez J A , Rodriguez Esparza J , Giraldo Echeverria N , Ortiz Leon X A , Fritche Salazar J F , Rodriguez Zanella H , Posada-Martinez E L , Ruiz Esparza M E , Millan Vela J R 
Published: January 2025

Abstract

Background
In patients with aortic stenosis (AS), the extent of extravalvular cardiac damage has a prognostic impact. Recent studies demonstrated that the coupling between the right ventricle and the pulmonary artery assessed as the relationship between the systolic excursion of the tricuspid annulus and pulmonary artery systolic pressure (TAPSE/PSAP) was a more effective predictor of mortality than conventional echocardiographic parameters in patients undergoing trans-catheter aortic valve implantation.

Purpose
The study aimed to evaluate the prognostic significance of right ventricular decoupling (TAPSE/PSAP index &lt;0.36 mm/mmHg) in patients with severe AS who underwent surgical aortic valve replacement (AVR).

Methods
This was an observational, longitudinal, and retrospective study of patients with severe AS who underwent surgical AVR between January 2016 and May 2023 in the National Institute of Cardiology Ignacio Chávez with a follow-up until December 2023. A composite of death and rehospitalization at 3 months was the endpoint. Survival analysis was performed with the generation of Kaplan Meier curves according to the TAPSE/PSAP value dichotomized at 0.36 mm/mmHg to assess survival and rehospitalization and was compared with the Log-rank statistical test.

Results
A total of 222 patients were included in the analysis, median age was 59 years (19-84), 36.9% were women, 27% had diabetes, 41% had arterial hypertension, and 24% had hyperlipidemia. Most patients (85%) were in NYHA functional class II. The median left ventricle ejection fraction was 58% (20-77). Patients were at low risk for surgical replacement according to EuroScore (median 1.1 [0.3-9.6) points] and Society of Thoracic Surgeons (STS) score (median 1.1 [0.04-5.8) points]; 26 patients (12%) died during follow-up. Figure 1 shows the echocardiographic characteristics, perioperative variables, and outcomes according to survival. There was no significant difference in the baseline, demographic, and clinical characteristics. Regarding echocardiographic parameters, the survival group had a higher right atrium volume [(27 (11-88) vs 22.5 (10-72) ml/m2, p=0.026] without significant differences in the size and function of the right and left ventricles, PSAP, and TAPSE/PSAP. As expected, the cardiopulmonary bypass time, aortic clamping time, blood cell transfusion, hours of intubation, and the incidence of postoperative complications were higher in the group of patients who died. There was no relation between the ventricle-arterial coupling and mortality, according to the dichotomic established value &lt;0.36mmHg (Figure 2).

Conclusion
In the present study, the right ventricle uncoupling did not predict clinical outcomes. Our findings could be explained because the extent of extravalvular cardiac damage in the majority of these patients was in Généreux stages 0 to 2 since the median values of RV function and PSAP was normal in both groups.
Figure 1
Figure 2