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Abstract Aims To analyse the predictive value of advanced markers of right ventricular (RV) function and RV-pulmonary arterial (PA) coupling in forecasting long-term left ventricular (LV) improvement in de novo heart failure with reduced ejection fraction (HFrEF). Methods and results 260 patients (mean age 57 years, 68% men) from the PROLONG-II study were included. PROLONG-II analysed patients with new-onset HFrEF receiving a wearable cardioverter-defibrillator. For this substudy, RV free wall longitudinal strain (RVFWS), tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and right ventricular-pulmonary artery (RV-PA) coupling ratios [RVFWS/systolic pulmonary artery pressure (PASP), TAPSE/PASP and FAC/PASP] at baseline and 3-month follow-up (early follow-up) were examined. LV improvement and non-improvement were defined as an LV ejection fraction (LVEF) of >35% or ≤35% at last available (long-term) follow-up. The median follow-up was 31.5 months (IQR: 18.2–45.4), and 151 (58%) patients experienced LV improvement in the long term. No significant differences of RV function and markers of RV-PA coupling were observed at baseline; however, the subgroup of patients with long-term LVEF improvement showed better RV function at early follow-up (RVFWS −20.9 ± 4.3 vs. −18.5 ± 5.1%, TAPSE 19.7 ± 5.1 vs. 17.4 ± 4.9 mm, FAC 39.7 ± 8.5 vs. 35.2 ± 9.4%, all P < 0.01). In multivariable analysis, RVFWS at early follow-up was shown to be an independent predictor of later LV recovery [odds ratio 1.078 (95% confidence interval 1.010–1.150), P < 0.05]. The non-improvers exhibited worse RV-PA coupling at early follow-up [RVFWS/PASP 0.82 ± 0.35 vs. 0.65 ± 0.35%/mmHg, TAPSE/PASP 0.71 (0.55–1.00) vs. 0.54 (0.35–0.75) mm/mmHg, FAC/PASP 1.54 ± 0.61 vs. 1.24 ± 0.75%/mmHg, all P < 0.01]. RVFWS/PASP identified RV-PA uncoupling was associated with a higher risk of all-cause mortality (hazard ratio 4.64, 95% confidence interval 1.34–16.09, P = 0.033). Conclusions Persistent RV dysfunction, as indicated by both standard and advanced echocardiographic markers during the early follow-up period, implies a reduced potential for long-term LV recovery in patients with newly diagnosed HFrEF.

The echocardiographic tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio is a non-invasive surrogate of right ventricular-pulmonary arterial (RV-PA) coupling which corresponds well with the respective invasively derived index. Recently, a wealth of observational data has arisen, outlining its prognostic value in heart failure (HF) patients. To systematically appraise and quantitatively synthesize the evidence of the prognostic value of TAPSE/PASP ratio in left-sided HF regardless of etiology or left ventricular ejection fraction. A systematic literature review was conducted in electronic databases to identify studies reporting the association of TAPSE/PASP ratio with outcomes in patients with HF and, when appropriate, a random-effects meta-analysis was conducted to quantify the unadjusted and adjusted hazard ratios [(a)HRs] for all-cause death and the composite outcome of all-cause death or HF hospitalization. Eighteen studies were deemed eligible encompassing 8,699 HF patients. The applied cut-off value for RV-PA uncoupling varied substantially from 0.27 to 0.58 mm/mmHg, and in most studies values lower than the applied cutoff conveyed dismal prognosis. Eleven studies reported appropriate data for meta-analysis. TAPSE/PASP reduction by 1 mm/mmHg was independently associated with all-cause death (pooled aHR=1.32 [1.06-1.65]; p=0.01; I2=56%) and the composite outcome (pooled aHR=3.48 [1.67-7.25]; p<0.001; I2=0%). When a TAPSE/PASP cutoff value of 0.36 mm/mmHg was applied it yielded independent association with all-cause death (pooled aHR=2.84 [2.22-3.64]; p<0.001; I2=82%). RV-PA coupling assessed by echocardiographic TAPSE/PASP ratio appears to be an independent outcome predictor for HF patients.

Hypoxia induced-pulmonary hypertension (HPH) is a life-threatening cardiovascular disorder prevalent in high-altitude regions. Right ventricular (RV) function and RV—pulmonary arterial (RV—PA) coupling are key to patient prognosis. Perillyl alcohol (POH), a natural compound, holds promise for managing pulmonary arterial hypertension (PAH). This study established HPH rat models via hypobaric chamber simulation (5000 m altitude) to explore the impact of POH on RV structure and function. Using a multi-modal approach, we employed echocardiography to assess RV function and RV-PA coupling. HE and Masson’s trichrome staining for tissue morphology and fibrosis. Immunohistochemistry, immunofluorescence, and western blotting to quantify collagen I/III and α-SMA. MDA, GSH, SOD, GSH-PX, IL-6 and TNF-α levels were measured using their respective commercial kits. ELISA/western blotting to analyze the ACE-Ang II-AT1R and ACE2-Ang (1–7)-MAS axes. Results showed that POH significantly restored RV function and RV-PA coupling, outperforming sildenafil in reducing RV structural changes (RVID-D, RVID-S, RVFT-D, RVFT-S). It normalized hypoxia-elevated hematological parameters (HCT, HGB, RBC), alleviated cardiomyocyte hypertrophy, fibrosis and inflammatory, and reversed RV remodeling. Mechanistically, POH exerted antioxidant effects and modulated the renin–angiotensin–aldosterone system (RAAS), decreasing ACE, Ang II, and AT1R levels while increasing ACE2, Ang (1–7), and MAS expression. In conclusion, POH improves RV function, preserves RV-PA coupling, and reduces RV systolic pressure, indicating its potential as an effective therapy for PAH patients.

Aims Traditional criteria for heart transplantation by cardiopulmonary exercise testing (CPX) include peak oxygen uptake (VO2) < 14 mL/kg/min. Reaching a sufficient exercise load is challenging for patients with refractory heart failure (HF) because of their exercise intolerance. Recently, a substantial impact of right ventricular (RV) dysfunction was highlighted on urgent heart transplantation and mortality. This study aims to investigate the impact of RV contractile reserve, assessed by low‐load exercise stress echocardiography (ESE), on exercise intolerance defined as peak VO2 < 14 mL/kg/min, in patients with HF. Methods and results We prospectively examined 67 consecutive patients hospitalized for HF who underwent ESE and CPX under a stabilized HF condition. Although low‐load ESE was defined as 25 W load exercise, an increment in RV systolic (s′) velocity was regarded as the preservation of RV contractile reserve. All patients completed low‐load ESE. During low‐load ESE, the variation in RV s′ velocity significantly correlated with peak VO2 (r = 0.787, P < 0.001). The change in RV s′ velocity during low‐load ESE accurately identified patients with peak VO2 < 14 mL/kg/min (area under the curve, 0.95; sensitivity, 92%; specificity, 85%). The intraclass correlation coefficient for intra‐observer and inter‐observer agreement for the change in RV s′ velocity was 0.96 (95% confidence interval, 0.88–0.99, P < 0.001) and 0.86 (95% confidence interval, 0.64–0.95, P < 0.001), respectively. The RV‐to‐pulmonary circulation (PC) coupling, which was assessed by the slope of the relationship between RV s′ velocity and pulmonary artery systolic pressure at rest and low‐load exercise, was worse in the low‐peak VO2 group (<14 mL/kg/min) than the preserved‐peak VO2 group (≥14 mL/kg/min). Conclusions The change in RV s′ velocity during low‐load ESE could estimate the exercise capacity in HF patients. The assessments of RV contractile reserve and RV‐to‐PC coupling could be clinically beneficial to distinguish high‐risk HF patients.

Objective Impaired right ventricular (RV)-pulmonary arterial (PA) coupling, calculated by measuring the tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP), can be used as an early indicator of right ventricular dysfunction (RVD) in patients with heart failure with a reduced ejection fraction (HFrEF). Patients suffering from HFrEF experience improvements in left ventricular (LV) function through the administration of sacubitril/valsartan therapy. In addition, the albumin-bilirubin (ALBI) score was associated with the fluid overload status and adverse clinical outcomes in patients with heart failure. This study aimed to assess whether angiotensin receptor-neprilysin inhibitor (ARNI) affects the TAPSE /PASP in patients with HFrEF, and whether there is a correlation between changes in the ALBI score and ARNI treatment. Methods A retrospective observational study was conducted on 305 patients with HFrEF and RVD who were hospitalized between June 2020 and December 2021. One year after treatment, laboratory test results, ALBI score, transthoracic echocardiography (TTE), New York Heart Association classification, Minnesota Living with Heart Failure Questionnaire scores and changes in relevant variables were reevaluated. Results Compared to before sacubitril/valsartan treatment, the ALBI was found to be significantly reduced after one year of follow-up (-2.42 ± 0.37 vs. -2.51 ± 0.32, p  < 0.001). Additionally, A significant improvement was demonstrated in the following echocardiography parameters assessing RV function after 1 year of treatment with sacubitril/valsartan: TAPSE (15 ± 1 vs. 18 ± 2 mm, p  < 0.001), PASP (45 ± 8 vs. 40 ± 9 mmHg, p  < 0.001), pulmonary artery diastolic pressure (PADP) (22 ± 4 vs. 19 ± 4 mmHg, p  < 0.001), RV-PA coupling (0.35 ± 0.08 vs. 0.48 ± 0.12, p  < 0.001), and RV s’(8.7 ± 2.2 vs. 9.5 ± 2.6 cm/s, p  < 0.001). Multivariate analysis showed that the improvement of RV-PA coupling was associated with baseline PASP ( r: -0.45, p  < 0.001) and PADP ( r: -0.45, p  < 0.001). Conclusions Sacubitril/valsartan improves RV-PA conjugation in patients with RVD and HFrEF, and has a positive impact on the ALBI score by improving liver function in patients with HFrEF.

Purpose of Review The right ventricle (RV) has a complex geometry and physiology which is distinct from the left. RV dysfunction and failure can be the aftermath of volume- and/or pressure-loading conditions, as well as myocardial and pericardial diseases. Recent Findings Echocardiography, magnetic resonance imaging and right heart catheterisation can assess RV function by using several qualitative and quantitative parameters. In pulmonary hypertension (PH) in particular, RV function can be impaired and is related to survival. Summary An accurate assessment of RV function is crucial for the early diagnosis and management of these patients. This review focuses on the different modalities and indices used for the evaluation of RV function with an emphasis on PH.

Background Right ventricular (RV) dysfunction in patients undergoing transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) has long been disregarded. We aimed to assess the predictive value of RV to pulmonary artery coupling (RV/PAc), defined as tricuspid annular plane systolic excursion to systolic pulmonary artery pressure, on mortality in different flow types of AS after TAVI. Methods All patients undergoing TAVI for AS at our centre between 2018 and 2020 were assessed; 862 patients were analysed. The cohort was dichotomized using a ROC analysis (cut-off 0.512 mm/mmHg), into 429 patients with preserved and 433 patients with reduced RV/PAc. Results Reduced RV/PAc was associated with male sex and a higher rate of comorbidities. Short-term VARC-3 endpoints and NYHA classes at follow-up were comparable. Reduced RV/PAc was associated with higher 2-year all-cause mortality (35.0% [30.3–39.3%] vs. 15.4% [11.9–18.7%], hazard ratio 2.5 [1.9–3.4], p  < 0.001). Cardiovascular mortality was almost tripled. Results were consistent after statistical adjustment and in a multivariate model. Sub-analyses of AS flow types revealed lower RV/PAc in classical and paradoxical low-flow low-gradient AS, with the majority having reduced RV/PAc (74% and 59%). RV/PAc retained its predictive value in these subgroups. Conclusions RV dysfunction defined by low RV/PAc is a strong mortality predictor after TAVI independent of flow group. It should be incorporated in future TAVI risk assessment. Graphical abstract

Background Pulmonary arterial hypertension (PAH) is a life-threatening condition characterized by elevated pulmonary artery pressure and progressive right ventricular dysfunction. The ratio of tricuspid annular plane systolic excursion to systolic pulmonary artery pressure (TAPSE/SPAP) has been proposed as a noninvasive marker integrating right ventricular function and afterload. This study aimed to evaluate the clinical and prognostic relevance of TAPSE/SPAP in patients with PAH. Methods and results This study was a retrospective analysis of 125 patients newly diagnosed with PAH at the Xiangya Second Hospital between 2016 and 2022. The patients were divided into two groups based on the median TAPSE/SPAP ratio: a low TAPSE/SPAP group and a high TAPSE/SPAP group. The primary outcome was survival and follow-up was conducted until December 2023. The results showed that a lower TAPSE/SPAP ratio (< 0.15 mm/mmHg) was significantly associated with worse survival outcomes, with a higher mortality rate in the low TAPSE/SPAP group (17/63, 27%) than in the high group (7/62, 11.3%). The low TAPSE/SPAP group also exhibited more severe right ventricular remodeling and worse hemodynamic parameters. A significant inverse correlation was found between TAPSE/SPAP and both World Health Organization functional class and NT-proBNP levels, suggesting its role in noninvasive risk stratification. Conclusion In this single-center retrospective cohort, a lower TAPSE/SPAP ratio was associated with more advanced disease and poorer outcomes in patients with PAH. Rather than serving as an independent prognostic predictor, TAPSE/SPAP may function as a composite, noninvasive marker reflecting right ventricular dysfunction and overall disease severity, and may be useful in clinical risk assessment when interpreted alongside established prognostic parameters.

Right ventricular–pulmonary artery coupling (RV-PA coupling) refers to the relationship between RV contractility and RV afterload. Normal RV-PA coupling is maintained only when RV function and pulmonary vascular resistance are appropriately matched. RV-PA uncoupling occurs when RV contractility cannot increase to match RV afterload, resulting in RV dysfunction and right heart failure. RV-PA coupling plays an important role in the pathophysiology and progression of cardiovascular diseases. Therefore, early and accurate evaluation of RV-PA coupling is of great significance for a patient’s condition assessment, clinical decision making, risk stratification, and prognosis judgment. RV-PA coupling can be assessed by using invasive or noninvasive approaches. The aim of this review was to summarize the pathological mechanism and evaluation methods of RV-PA coupling, the advantages and disadvantages of each method, and the application value of RV-PA coupling in various cardiovascular diseases.

Aims Novel echocardiographic parameters of right ventricular (RV) function, including speckle‐tracking‐derived, three‐dimensional, and RV–pulmonary artery coupling parameters, have emerged for the evaluation of pulmonary arterial hypertension (PAH). The relative role of these parameters in the risk stratification of PAH patients is unclear. We compared the performance of multiple RV parameters and sought to establish an optimal model for identifying the risk profile of patients with PAH. Methods and results Comprehensive risk assessments were performed for 70 patients with PAH. The risk profile of every patient was determined based on the guideline recommendations. Conventional parameters, including fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE), novel speckle‐tracking‐derived RV longitudinal strain (RVLS), and three‐dimensional RV ejection fraction (3D‐RVEF), were used to evaluate RV function. Pressure–strain loops were measured for the assessment of RV myocardial work, including RV global wasted work (RVGWW). RV–pulmonary artery coupling was assessed by indexing RV parameters to the estimated pulmonary artery systolic pressure (PASP). The median age was 34 (30–43) years, and 62 (88.6%) patients were female. Forty‐five patients were classified into the low‐risk group, while 25 patients were classified into the intermediate–high‐risk group. Most RV parameters could be used to determine the risk profile and exhibited significantly improved diagnostic performance after indexing to PASP (including FAC/PASP, TAPSE/PASP, and 3D‐RVEF/PASP). RVLS/PASP showed the best performance, with an area under the curve of 0.895. In multivariate analysis (Model 1), only RVGWW (>90.5 mmHg%), RVLS (> −16.7%), and TAPSE (<17.5 mm) remained significant (all P < 0.05). Model 1 outperformed every single RV parameter, with a significantly larger area under the curve (all P < 0.05). With PASP indexing in Model 2, RVLS/PASP > −0.275 [odds ratio (OR) 20.63, 95% confidence interval (CI) 4.62–92.11, P < 0.001] and RVGWW > 90.5 mmHg% (OR 6.17, 95% CI 1.37–27.76, P = 0.018) independently identified a higher risk profile. The addition of RVGWW to two models determined incremental value in identification (continuous net reclassification improvement 1.058, 95% CI 0.639–1.477, P < 0.001). Conclusions The combination models for RV function outperformed any single parameter in identifying the risk profile of patients with PAH. Comprehensive assessment of RV–pulmonary artery coupling using multiparametric methods is clinically meaningful in patients with PAH.