Integrating right ventricular pulmonary coupling and venous congestion to predict outcomes in acute heart failure
F Ben Ghorbel, S Antit, L ZakhamaAbstract
Background
Right-sided heart failure (HF) is associated with poor prognosis, largely driven by systemic venous congestion leading to multi-organ dysfunction and hypoperfusion. Right ventricular–pulmonary arterial coupling reflects the interaction between right ventricular (RV) systolic function and pulmonary afterload, and the TAPSE/PASP ratio has emerged as a relevant prognostic marker in HF. In parallel, the Venous Excess Ultrasound (VExUS) score provides a bedside Doppler-based assessment of systemic venous congestion and represents a promising tool for risk stratification of adverse HF outcomes.
Purpose
We sought to evaluate the prognostic value of the TAPSE/PASP ratio and the VExUS score, alone and in combination, for a composite endpoint of HF rehospitalisation and/or all-cause mortality in patients hospitalised for acute heart failure (AHF).
Methods
This monocentric, prospective study with a cross-sectional assessment and longitudinal follow-up was conducted between February and December 2024. Consecutive adult patients (≥18 years) admitted to the intensive care unit for acute de novo HF or acute decompensation of chronic HF were considered for inclusion. Patients with chronic haemodialysis, severe baseline renal impairment (creatinine clearance <30 mL/min), liver cirrhosis, portal hypertension, or inferior vena cava thrombosis were excluded. Clinical, biological, and echocardiographic data were collected during the index hospitalisation. Patients were followed at 3 and 6 months after discharge to assess a composite endpoint defined as HF rehospitalisation and/or all-cause mortality. The VExUS score was systematically assessed 24 hours after admission, at discharge, and at three-month follow-up.
Results
Among 87 patients hospitalised for AHF, 60.9% experienced the composite endpoint, of whom 71.7% had severe venous congestion defined by VExUS grade 3. Patients with moderate-to-severe congestion (VExUS 2–3) had a significantly lower TAPSE/PASP ratio compared with those with no or mild congestion (VExUS 0–1) (0.28 ± 0.10 vs. 0.41 ± 0.18; p = 0.001). In multivariable analysis, the composite endpoint was independently associated with severe venous congestion (VExUS grade 3; OR 7.50, 95% CI 2.60–11.64; p < 0.001) and with the TAPSE/PASP ratio (OR 2.93, 95% CI 1.04–8.27; p = 0.043). VExUS grade 3 showed good discriminative performance for the composite endpoint (AUC 0.78), as did the TAPSE/PASP ratio (AUC 0.73). The combined assessment of VExUS grade 3 and TAPSE/PASP further improved discrimination (AUC 0.85), with 76.5% sensitivity, 81.9% specificity, a positive predictive value of 85.7%, and a negative predictive value of 71.8%.
Conclusion
Severe venous congestion combined with impaired RV–pulmonary arterial coupling defines a high-risk hemodynamic phenotype in AHF and improves prediction of clinically relevant outcomes.