Right Ventricular to Pulmonary Artery Coupling and Clinical Outcomes after Interatrial Shunting in Heart Failure: Exploratory Analysis of the PRELIEVE study

AIMS: Heterogeneous outcomes were reported in studies targeting left atrial (LA) pressure reduction by interatrial shunting in heart failure (HF). Right ventricular (RV) performance and pulmonary arterial (PA) afterload are essential in assuring the efficient blood flow shunting through the pulmonary circulation. We investigated whether baseline RV-PA coupling, expressed as the tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio, is associated with outcomes after Atrial Flow Regulator (AFR) implantation in the PRELIEVE study. METHODS AND RESULTS: In this post-hoc analysis of the multicentre, single-arm PRELIEVE study (NCT03030274), 106 patients with symptomatic HF (62 with reduced and 44 with preserved ejection fraction) underwent AFR implantation and were followed for 12 months. TAPSE/PASP was measured by echocardiography at baseline and 3 months. The primary composite endpoint was cardiovascular (CV) death or HF hospitalization (HFH).During follow-up, 19 patients (18%) experienced the composite endpoint. At baseline, these patients had higher NT-proBNP (1261 [567, 1790] vs. 317 [114, 1200] pg/mL; p=0.009) and lower TAPSE/PASP (0.43 [0.33-0.53] vs 0.53 [0.43-0.76], p=0.04). In Kaplan-Meier analysis, lowest TAPSE/PASP ratio tended to show the worst outcome (p=0.07). Using recurrent-event Poisson regression, lower baseline TAPSE/PASP was associated with a higher cumulative incidence of HFHs (incidence rate ratio 2.4 [95% CI 1.0-5.6] for lowest vs middle tertile, p=0.039). CONCLUSIONS: In patients with HF undergoing interatrial shunting, impaired baseline RV-PA coupling assessed by a low TAPSE/PASP ratio was associated with higher rates of CV death or recurrent HF hospitalizations. The potential value of baseline RV-PA uncoupling in identifying responders to LA shunt therapies requires prospective evaluation in adequately powered prospective studies.