Right heart function matters: prognostic value of sPAP, TAPSE and RV–PA coupling in a real-world cohort of TAVI patients

Right ventricular (RV) function is an established prognostic factor in structural heart disease, but is not routinely incorporated into pre-procedural risk assessment in patients undergoing transcatheter aortic valve implantation (TAVI). This study evaluated the prognostic impact of systolic pulmonary artery pressure (sPAP), tricuspid annular plane systolic excursion (TAPSE), and RV–pulmonary artery (PA) coupling (TAPSE/sPAP ratio) in a real-world TAVI population. This retrospective single-center study included 565 consecutive patients (mean age 82.1 ± 5.1 years; 48.7% male) undergoing transfemoral TAVI between 2016 and 2022. All patients received standardized pre-procedural echocardiographic assessment of sPAP, TAPSE, and TAPSE/sPAP. The primary endpoint was all-cause mortality over a mean follow-up of 47.1 ± 22.8 months. Impaired RV–PA coupling – defined as a TAPSE/sPAP < 0.55 mm/mmHg – was identified in 46.5% of patients, elevated sPAP (≥35 mmHg) in 61.2%, and reduced TAPSE (≤18 mm) in 22.3%. Both elevated sPAP and reduced TAPSE/sPAP were significantly associated with increased long-term mortality (p=0.004 and p<0.001, respectively), whereas TAPSE alone was not predictive (p=0.318). Subgroup and interaction analyses showed that the prognostic impact of sPAP and TAPSE/sPAP was greatest in patients aged ≥80 years, in males, and in those with preserved left ventricular ejection fraction and normal stroke volume index (SVi).RV afterload, as reflected by elevated sPAP and impaired RV–PA coupling, is a key driver of post-TAVI mortality, outperforming isolated RV systolic measurements. The TAPSE/sPAP ratio is a robust, integrative marker whose prognostic value is modulated by age, sex and left heart function. These findings support incorporating RV–PA coupling into routine pre-TAVI assessment to improve risk stratification and identify vulnerable patients before intervention