Novel Prognostic Insights in Multivalvular Disease: the Crucial Role of Right Ventricular–Pulmonary Artery Coupling

Background: To our knowledge, the prognostic role of right ventricular-pulmonary artery coupling (RV-PAc) in the context of multiple valvular heart disease (MVD) has so far not been evaluated. Therefore, in this study we assessed the prognostic role of surrogate of RV-PAc in patients affected by one of the most common MVDs: moderate mitral regurgitation (MR) with concomitant moderate tricuspid regurgitation (TR). Methods: We collected comprehensive data of patients with coexisting moderate MR and moderate TR at 2 centers between 2014 and 2021. The outcome of interest was all-cause death. RV-PAc was estimated using the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio. Results: In the 905 patients included in our study (median age 78 years, 53% female), the relative hazard of the outcome analysis identified ≤ 0.36 as the TAPSE/PASP threshold associated with a hazard > 1.0. At baseline, TAPSE/PASP ≤ 0.36 was associated with worse New York Heart Association class, greater prevalence of atrial fibrillation, and worse remodeling of left- and right-sided chambers (all P < 0.005). After a median follow-up of 2.3 years, compared to patients with TAPSE/PASP > 0.36, those with a low TAPSE/PASP ratio showed significantly worse survival (P < 0.001), and TAPSE/PASP ≤ 0.36 remained a powerful predictor of outcome after adjustment for crucial clinical and echocardiographic variables. Finally, the nested Cox regression model showed an incremental prognostic role of TAPSE/PASP compared with its constituents TAPSE and PASP as separate variables (P value of improved model fit = 0.008). Conclusions: In this large cohort of patients with moderate MR + moderate TR, RV-PAc estimated by TAPSE/PASP was strongly associated with worse baseline clinical presentation and poor long- term prognosis.