The association of right ventricular to pulmonary arterial coupling with mortality: a systematic review and meta-analysis
C Kocx, A Burbidge, B Tucker, S LalAbstract
Background
Right ventricular to pulmonary arterial (RV-PA) uncoupling may represent a final common pathway of maladaptation regardless of underlying cardiopulmonary insult. The ratio of tricuspid annular plane systolic excursion to estimated pulmonary artery systolic pressure (TAPSE/PASP) provides a simple echocardiographic surrogate of RV-PA coupling. If RV-PA uncoupling is truly a terminal haemodynamic derangement, its prognostic impact should be consistent across diverse pathologies.
Purpose
Investigate the disease-agnostic prognostic impact of TAPSE/PASP on all-cause mortality.
Methods
A systematic search of five databases was performed (PROSPERO: CRD420251137357). Studies including > 50 participants with established cardiopulmonary disease and > 6 months follow-up reporting univariate and/or multivariate associations of TAPSE/PASP with all-cause mortality based on survival analysis were included. Pooled estimates were calculated using random-effects models separately for unadjusted and adjusted estimates with TAPSE/PASP analysed as both dichotomous and continuous predictors.
Results
Of 1,348 studies identified, 378 underwent full-text review and 56 met inclusion criteria. 20 studies reported dichotomised TAPSE/PASP associations with mortality, 22 used continuous TAPSE/PASP, and 14 reported both. Mean threshold defining uncoupling was 0.41 mm/mmHg. In pooled unadjusted analysis, RV-PA uncoupling was associated with 2.4-fold higher mortality risk (95% CI: 2.15–2.68; p<0.001; I²=48.8%). Adjusted estimates (n=26) were consistent (HR 1.88 [1.67–2.12]; p<0.001; I²=60.7%). The association remained consistent irrespective of underlying pathology, valve disease type, LVEF in heart failure trials, or heart failure chronicity (subgroup p all ≥0.1). As a continuous predictor, each 1 mm/mmHg increase in TAPSE/PASP was associated with 78% lower mortality (95% CI [0.15–0.31], p<0.001) with analogous adjusted results (HR 0.36 [0.24–0.54]; p<0.001). Egger's test showed weak evidence of funnel plot asymmetry (p=0.03), though results were consistent using trim-and-fill and leave-one-out analyses.
Conclusion
RV-PA uncoupling assessed by TAPSE/PASP predicts mortality consistently across diverse cardiopulmonary conditions. The absence of significant effect modification by underlying pathology, ventricular function, or heart failure phenotype supports RV-PA uncoupling as a terminal haemodynamic derangement irrespective of upstream aetiology. TAPSE/PASP merits routine assessment as a disease-agnostic prognostic marker.