The independent role of right ventricular to pulmonary artery coupling for heart failure with improved ejection fraction

Introduction

Heart failure (HF) with improved (imp) ejection fraction (EF) is a newly acknowledged HF phenotype relatively understudied, with significant uncertainty regarding its clinical and paraclinical profile as well as its prognostic implications.

The ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) estimated by echocardiography provides a non-invasive method to assess right ventricular (RV)-pulmonary artery (PA) coupling. Reduced TAPSE/PASP values were recently correlated with mortality in HF with reduced ejection fraction (HFrEF).

Purpose

Hypothesising that higher TAPSE/PASP values might signal a more favourable outcome for HFrEF patients, we sought to evaluate the prognostic role of this ratio in predicting LVEF improvement after hospitalization for HFrEF.

Methods

This is a retrospective, observational, single-center unmatched case-control study that included HFrEF patients previously hospitalized for HF and reevaluated between January-October 2025, with subsequent improved or persistently reduced EF. HFimpEF was defined as baseline LVEF ≤40%, improved to >40%, with a ≥ 10% increase.

Receiver operating characteristic (ROC) analysis was used to assess the association of clinical and echocardiographic parameters with LVEF improvement, as well as optimal cut-off values, sensitivity (Se), and specificity (Sp), based on the Youden index criterion. Multivariable logistic regression analysis was employed to determine the independent predictors of HFimpEF.

Results

Our study included 103 HFrEF patients (mean age 68.2±9.5 years; 66% male); 31 (30.1%) developed HFimpEF.

In univariable analysis, TAPSE (AUC 0.64, 95% CI 0.53 – 0.72, cut-off >19mm, Se 48%, Sp 82%, p=0.02), PASP (AUC 0.67, 95% CI 0.57-0.76, cut-off<38mmHg, Se 58%, Sp 71%, p=0.002), TAPSE/PASP (AUC 0.70, 95% CI 0.61-0.79, cut-off>0.56 mm/mmHg, Se 52%, Sp 85%, p<0.001), NYHA class (AUC 0.66, 95%CI 0.56-0.75, p<0.001), and successful cardioversion of atrial fibrillation (OR 9.35, 95%CI 2.68-32.58, p<0.001) were associated with EF recovery. Age, sex, NT-proBNP and baseline LVEF were not correlated with HFimpEF.

In multivariable analysis, TAPSE/PASP >0.56 mm/mmHg (OR 7.60, 95% CI 1.17-49.22, p=0.03) was an independent predictor of LVEF recovery, along with lower NYHA class (OR 0.39, 95% CI 0.17-0.84, p=0.01) and successful cardioversion (OR 12.17, 95% CI 2.91-50.81, p<0.001), outperforming PASP<38mmHg and TAPSE>19mm.

Conclusions

In a single-centre cohort of HFrEF patients, TAPSE/PASP >0.56mm/mmHg was an independent predictor of LVEF improvement after a follow-up period of at least 6 months.For image description, please refer to the figure legend and surrounding text.