RV-Pulmonary Artery Coupling Prognosis in Cardiac Resynchronization Therapy

Ultrasound echocardiogram of a patient taking a test for heart diseases. Echocardiogram monitor with an image of patient’s heart. Medical ultrasound scan.
A study was conducted to evaluate the evolution and prognostic value of TAPSE/PASP ratio in cardiac resynchronization therapy recipients.

Among patients undergoing cardiac resynchronization therapy, there is a positive association for long-term outcomes with a tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) ratio equal to or greater than 0.45 mm/mm Hg and failure to improve the TAPSE/PASP ratio following cardiac resynchronization therapy is negatively associated with long-term outcomes. These findings were published in ESC Heart Failure.

Patients with heart failure (HF) who experience right ventricular (RV) dysfunction and chronic pressure overload may face RV-pulmonary artery uncoupling. In patients subsequently treated with cardiac resynchronization therapy (CRT), the prognostic usefulness of echocardiography assessing RV-pulmonary artery coupling has not been comprehensively analyzed. Researchers sought to evaluate the long-term predictive value of the TAPSE/PASP ratio in patients receiving CRT.

To accomplish this, they conducted a single-center retrospective study that included 807 patients (aged 66±11 years; 76% men) with HF and subsequent CRT implantation at the Leiden University Medical Center, the Netherlands. Echocardiographic evaluation was performed before CRT implantation and repeated at the 6-month follow-up. At baseline, 45% of patients had a TAPSE/PASP ratio of less than 0.45 mm/mm Hg. These patients were more likely to have a lower performance on the 6-minute walk test, diabetes, more impaired renal function, worse quality of life score, a lower body mass index, and to be NYHA functional Class III–IV. All-cause death was the primary endpoint.

In all, 483 patients (60%) died during the median follow-up of 97 (54-143) months.  Patients with a TAPSE/PASP ratio below 0.45 mm/mm Hg had significantly lower survival rates at 3 and 5 years (76% and 58%, respectively) than patients with a TAPSE/PASP ratio of 0.45 mm/mm Hg or higher (91% and 82%, respectively; P <.001). A TAPSE/PASP ratio of less than 0.45 mm/mm Hg was independently associated with death due to any reason; however, TAPSE of less than 17 mm analyzed alone was not (mean TAPSE, 16.1±4.8). After CRT implantation, failure of the TAPSE/PASP ratio to improve was also independently associated with death.

Some study limitations were that this was conducted in a single-center and RV- pulmonary artery coupling was only measured at rest. There was also a lack of end-systolic elastance/arterial elastance data and an inability to distinguish between cardiac and non-cardiac mortality.

The researchers wrote, “The TAPSE/PASP ratio, measured non-invasively with echocardiography, is independently associated with long-term outcomes in CRT recipients. Baseline TAPSE/PASP ratio has incremental value over TAPSE, which does not take account of RV afterload, and may therefore improve risk stratification of patients receiving CRT.” They also noted that worse survival had been associated with the TAPSE/PASP ratio when it failed to improve after CRT.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Stassen J, Galloo X, Hirasawa K, et al. Right ventricular-pulmonary artery coupling in cardiac resynchronization therapy: evolution and prognosis. ESC Heart Fail. Published online March 9, 2022. doi:10.1002/ehf2.13857