PURPOSE: Right ventricular (RV) function, as assessed hemodynamically, has prognostic value in pulmonary arterial hypertension (PAH). Despite similar hemodynamic characteristics, patients with PAH associated with scleroderma (PAH-SSD) have poorer response to therapy and worse prognosis compared to other forms of PAH. Because rapid clinical deterioration is common in PAH-SSD, non-invasive measures of RV function are particularly important. We examined whether the tricuspid annular plane systolic excursion (TAPSE) is a useful measure of RV function with prognostic significance in PAH-SSD.
METHODS: 24 consecutive patients with PAH-SSD underwent right heart catheterization (RHC), trans-thoracic echocardiogram (TTE) and were followed prospectively. Measures of RV function were assessed on TTE, including TAPSE (the total displacement of the tricuspid annulus from end-diastole to end-systole). The ability of TAPSE to detect RV systolic dysfunction was tested using ROC curves comparing TAPSE to RV stroke volume index and cardiac index. Time-to-event analyses were performed to examine the relationship between TTE-derived measures of RV function and survival.
RESULTS: RHC revealed moderate to severe PAH (mean RAP 11±6 mmHg, mean PAP 46±9 mmHg, mean CI 2.2±0.6 L/min/m2, mean PVR 11±5 Wood units). The reproducibility of TAPSE was excellent. 13 of 24 patients died in the follow up period (median 16.7 months, range 1.1-25.9). Median survival was 15.1 months. One-year survival estimates based on TAPSE were 86% (95% CI, 33-98%) for the group with TAPSE > 1.8cm and 47% (95% CI, 23-68%) for the group with TAPSE < 1.8cm (log-rank P=0.02). In univariable Cox proportional hazards analysis, TAPSE <1.8cm conferred a 7.5-fold increased risk of death compared to those with a TAPSE > 1.8cm (95% CI, 1.1-57.7, P = 0.05). When included as a continuous variable, for every decrease in TAPSE of 1mm, the risk of death increased by 15% (HR 1.15, 95% CI, 1.01-1.31, P = 0.04).
CONCLUSION: In patients with PAH-SSD, TAPSE is a simple and reproducible assessment of RV function with strong prognostic value.
CLINICAL IMPLICATIONS: Future studies of TAPSE in PAH should be conducted to confirm these findings.
DISCLOSURE: Stephen Mathai, None.