Pulmonary Artery Pulsatility Index Refines Prognostic Value of RV-PA Coupling in Patients Undergoing Transcatheter Tricuspid Valve Interventions

Clin Res Cardiol (2025). DOI 10.1007/s00392-025-02625-4
K.-P. Rommel (Mainz)¹, G. Bonnet (Bordeaux)², L. Stolz (München)³, S. Ludwig (Hamburg)⁴, V. Fortmeier (Bad Oeynhausen)⁵, A. Schöber (Mainz)⁶, J. von Stein (Köln)⁷, M. Kassar (Bern)⁸, M. Gercek (Bad Oeynhausen)⁵, T. Stocker (München)³, M. I. Körber (Köln)⁹, K.-P. Kresoja (Mainz)⁶, T. Kister (Leipzig)¹⁰, D. Kalbacher (Hamburg)¹¹, R. Pfister (Köln)⁹, S. Baldus (Köln)⁷, S. Windecker (Bern)¹², H. Thiele (Leipzig)¹⁰, F. Praz (Bern)¹², J. Hausleiter (München)³, V. Rudolph (Bad Oeynhausen)⁵, J. Granada (New York)¹³, P. Lurz (Mainz)^6
1Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie Mainz, Deutschland; ²Hopital Cardiologique Haut-Lévêque Bordeaux, Frankreich; ³LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ⁴Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ⁵Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; ⁶Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; ⁷Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; ⁸Inselspital - Universitätsspital Bern Universitätsklinik für Kardiologie Bern, Schweiz; ⁹Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ¹⁰Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; ¹¹Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland; ¹²Inselspital - Universitätsspital Bern Bern, Schweiz; ¹³Cardiovascular Research Foundation New York, Deutschland

Background:
The pulmonary artery pulsatility index (PAPi) predicts right heart failure (RHF) in various clinical scenarios, including moderate-to-severe tricuspid regurgitation (TR) managed medically. Its role in patients undergoing transcatheter tricuspid valve interventions (TTVI) remains elusive. This study aimed to evaluate the association of PAPi with clinical characteristics and outcomes in severe TR patients undergoing TTVI.

Methods:
In a multicenter international TTVI registry, 981 severe TR patients had PAPi (PA pulse pressure to right atrial pressure ratio) invasively assessed before TTVI and were followed up to 2 years for mortality.

Results:
Average age was 79±7 years, 55% were women. PAPi levels decreased with increasing TR severity (p<0.01). Overall, 45% had a PAPi<2. These patients were younger, had higher NYHA class, more RHF signs, lower LVEF, lower TAPSE, lower PA systolic pressures, and a better RV/PA coupling ratio as compared to PAPi≥2 patients (p<0.05 for all). The 2-year mortality rate was higher with PAPi<2 (36% vs. 28%, p<0.01). PAPi was significantly associated with mortality in Cox regression both continuously and as a binary variable (PAPi≥2), even after multivariable adjustment. Adding PAPi to the RV/PA coupling ratio (TAPSE/sPAP) improved risk stratification for 2-year mortality (net reclassification index=0.23).

Conclusion:
In severe TR patients undergoing TTVI, PAPi is linked to advanced biventricular heart failure and 2-year mortality. PAPi adds value to risk stratification with RV/PA coupling, suggesting its potential for patient selection.