Background
Patients undergoing transcatheter aortic valve implantation (TAVI) often have coexisting chronic kidney disease (CKD) and metabolic comorbidities, further complicating risk stratification in this patient cohort. Right ventricular–pulmonary artery (RV–PA) coupling, assessed by the tricuspid annular plane systolic excursion to systolic pulmonary artery pressure ratio (TAPSE/sPAP), is a promising prognostic indicator. However, its incremental prognostic value in TAVI patients, especially in the context of varying cardiovascular-kidney-metabolic (CKM) comorbidity burden, remains unclear. We aimed to evaluate the prognostic value of TAPSE/sPAP on 36-month outcomes after TAVI and determine its predictive utility differs across CKM phenotypes (no burden, metabolic-only, kidney-only, combined).
Methods
We studied 886 TAVI patients, who were stratified by CKM phenotype: no burden (neither CKD nor metabolic disease), metabolic-only, kidney-only, and combined (both CKD and metabolic disease). Baseline TAPSE/sPAP was measured by echocardiography. The primary outcomes were 36-month cardiovascular (CV) mortality, all-cause mortality, and heart failure (HF) hospitalization. Cox proportional hazards models evaluated associations of TAPSE/sPAP with outcomes in the overall cohort and within each subgroup.
Results: Over 36 months, TAPSE/sPAP emerged as the strongest independent predictor of all outcomes in the overall cohort. Higher TAPSE/sPAP (better RV–PA coupling) was associated with significantly lower risk of CV death, all-cause mortality, and HF hospitalization (all p<0.01). In subgroup analysis, the prognostic impact of TAPSE/sPAP was most pronounced in patients with CKD. In the kidney-only subgroup, each unit increase in TAPSE/sPAP was associated with ~78% lower risk of CV death (HR 0.22 [0.07–0.76], p=0.016) and ~68% lower risk of HF hospitalization (HR 0.32 [0.12–0.83], p=0.019). Similarly, patients with combined CKD and metabolic burden showed a strong trend toward better 36-month outcomes with higher TAPSE/sPAP. In contrast, TAPSE/sPAP had no significant prognostic value in patients without CKD (no-burden and metabolic-only groups).
Conclusion: TAPSE/sPAP, an index of RV–PA coupling, provides clinical relevant prognostic information beyond traditional risk factors or comorbidities in TAVI patients, especially in those with CKD. These findings suggest that impaired right heart–pulmonary vascular interaction confers incremental risk not captured by systemic comorbidity burden alone. Clinically, TAPSE/sPAP could be routinely integrated into TAVI risk assessment alongside CKM classification to identify high-risk patients (particularly those with CKD), who may benefit from closer follow-up and tailored interventions.
