Baseline right ventricular-pulmonary artery uncoupling and mortality following transcatheter aortic valve replacement: a meta-analysis

Abstract Background In severe aortic stenosis (AS) patients, elevated left-sided filling pressures can lead to pulmonary hypertension and right ventricular (RV) systolic dysfunction. These conditions signal advanced disease and predict poor outcomes in transcatheter aortic valve replacement (TAVR) cases. However, recent studies indicate potential recovery post-TAVR, with improved prognosis. The newly recognized index, RV to pulmonary artery (RV-PA) coupling, reflects the RV's ability to handle pulmonary afterload and is associated with adverse outcomes. Purpose This study aimed to delineate the prognostic role of baseline RV-PA uncoupling in patients undergoing TAVR. Methods We conducted a systematic literature search for studies assessing RV-PA coupling indices at baseline in patients undergoing TAVR. We recorded the year of publication, method of RV-PA assessment, the proposed cutoffs, patients’ age-sex, and follow-up duration. The primary outcome of interest was all-cause mortality at maximal follow-up and the adjusted hazard ratios of RV-PA uncoupling for all-cause mortality were extracted. Pooling of the hazard ratios was conducted according to a random effects model. I2 was chosen as the measure of between-study heterogeneity, with values exceeding 50% being significant. Results We identified a total of 316 studies, of which 5 were ultimately selected for data extraction and inclusion in the meta-analysis after screening of title/abstract/full-text. All but one study utilized the Tricuspid Annular Plane Systolic Excursion/Pulmonary artery systolic pressure (TAPSE/PASP) as the method of RV-PA assessment. The mean age of the participants across the studies was approximately 81 years old, with a balanced male:female ratio. The median follow-up duration was 23 months (range: 6-40 months). According to the results of the meta-analysis, the presence of baseline RV-PA uncoupling was associated with a 2.8-fold increased risk of all-cause mortality at maximal follow-up (Figure). Significant between-study heterogeneity was detected. An asymmetric funnel plot was inspected, indicative of publication bias (Egger’s test intercept: 6.76, 95% confidence interval 5.07-8.44, p=0.004). The results, although attenuated, remained significant even after a trim-and-fill analysis (3 studies added, hazard ratio: 1.27, 95% confidence interval: 0.03-2.51, p=0.04). Furthermore, the results were unaffected following a sensitivity analysis with the leave-one-out method. Conclusion This meta-analysis suggests that baseline RV-PA uncoupling prior to TAVR is associated with all-cause mortality and it could serve as an imaging biomarker of prognosis in this patient population.Figure