Research Intern Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval Québec, Quebec, Canada
Background: Aortic stenosis (AS) is the most common valvular heart disease in high-income countries. To date, aortic valve replacement (AVR), whether surgical or transcatheter, remains the only available therapeutic option. The management of AS patients mainly relies on the presence of symptoms and left ventricular function. In contrast, the assessment of right ventricular function, particularly right ventricular-pulmonary arterial coupling, may represent a promising avenue to improve patient management.
METHODS AND RESULTS: 133 patients with severe asymptomatic AS from the prospective observational PROGRESSA cohort (NCT01679431) were included. The TAPSE/sPAP ratio was assessed from echocardiograms performed at the time of severe AS diagnosis. Its association with all-cause mortality was evaluated using univariable and multivariable Cox regression models, adjusting for age, sex, and aortic jet velocity. Receiver Operating Characteristic (ROC) curves and the Youden index were used to determine optimal prognostic thresholds. Survival was analyzed using Kaplan-Meier curves. To assess the incremental prognostic value of the TAPSE/sPAP ratio beyond conventional variables, we performed a likelihood ratio test comparing a baseline Cox model (including age, sex, and aortic jet velocity) to an extended model incorporating TAPSE/sPAP.
The mean age of the cohort was 68.4±12.5 years, with 100 (75%) men. During a median follow-up of 7.8 (5.3–11.1) years, 52 patients (39%) died. In univariable Cox analysis, TAPSE/sPAP ratio (1/HR [95%CI]: 25.0 [3.7-100.0] per one unit decrease, p< 0.001) was significantly associated with an increased risk of mortality. In multivariable model adjusted for age, sex, and aortic jet velocity, TAPSE/sPAP (1/HR [95%CI]: 9.1 [1.6-50.0] per one unit decrease, p = 0.01) remained independently associated with a higher risk of mortality. An optimal cutoff of ≤ 0.76 mm/mmHg was identified (AUC = 0.688, p< 0,001). Kaplan-Meier survival curves revealed significantly reduced survival in patients with TAPSE/sPAP ≤ 0.76 mm/mmHg (log-rank test p = 0.003). The addition of TAPSE/sPAP significantly improved the model's prognostic performance compared to the baseline model, as demonstrated by the likelihood ratio test (LR χ² = 8.1, p = 0.005).
Conclusion: Lower TAPSE/sPAP ratio is strongly and independently associated with increased risk of mortality in asymptomatic patients with severe AS. These results support its integration into risk stratification strategies and highlight the need for validation in larger prospective studies.
