Prognostic value of TAPSE/sPAP ratio across cardiovascular–kidney–metabolic phenotypes after TAVI

Background

Patients undergoing transcatheter aortic valve implantation (TAVI) frequently present with chronic kidney disease (CKD) and metabolic comorbidities, complicating risk stratification. Right ventricular–pulmonary artery (RV–PA) coupling, assessed by the tricuspid annular plane systolic excursion to systolic pulmonary artery pressure ratio (TAPSE/sPAP), has emerged as a potential prognostic marker. However, its prognostic relevance across distinct cardiovascular–kidney–metabolic (CKM) phenotypes remains unclear.

Methods

We analysed 886 consecutive TAVI patients stratified into four CKM phenotypes (no burden, metabolic-only, kidney-only, combined). Baseline TAPSE/sPAP was measured by echocardiography. The primary endpoints were 36-month cardiovascular (CV) mortality, all-cause mortality, and heart failure (HF) hospitalisation. Cox regression and classification and regression tree (CART) analysis were performed to assess prognostic impact and derive optimal cut-points.

Results

Baseline TAPSE/sPAP differed significantly across CKM phenotypes (overall p<0.001; Figure 1). Mean values were 0.599±0.295 in the no-burden group (n=229), 0.557±0.258 in the metabolic-only group (n=125), 0.489±0.231 in the kidney-only group (n=346), and 0.525±0.285 in the combined group (n=186). TAPSE/sPAP was lowest in the kidney-only phenotype (p<0.001 vs no burden; p=0.048 vs metabolic-only).

Using data-driven cut-points (≤0.318, 0.319–0.623, >0.623), Kaplan–Meier analysis demonstrated stepwise increases in 36-month event rates across decreasing TAPSE/sPAP categories (Figure 2). All-cause mortality was 18.4% for >0.623, 25.9% for 0.319–0.623, and 35.2% for ≤0.318 (log-rank p=0.003). Similar graded associations were observed for CV mortality (log-rank p=0.003) and HF hospitalisation (log-rank p<0.001).

In multivariable analysis, higher TAPSE/sPAP was independently associated with lower risk of CV death, all-cause mortality, and HF hospitalisation (all p<0.01). The prognostic impact was most pronounced in patients with CKD. In the kidney-only phenotype, each unit increase in TAPSE/sPAP was associated with reduced CV death (HR 0.22, 95% CI 0.07–0.76; p=0.016) and HF hospitalisation (HR 0.32, 95% CI 0.12–0.83; p=0.019).

Conclusion

TAPSE/sPAP provides incremental prognostic information beyond CKM burden in TAVI patients. Lower TAPSE/sPAP identifies progressively higher mortality and HF risk, particularly in the kidney-only phenotype, supporting integration of RV–PA coupling into post-TAVI risk assessment.Figure 1 For image description, please refer to the figure legend and surrounding text.Figure 2For image description, please refer to the figure legend and surrounding text.