Online first
Original Article
Published online: 2023-09-12

open access

Page views 438
Article views/downloads 203
Get Citation

Connect on Social Media

Connect on Social Media

Right ventricle to pulmonary artery coupling as a predictor of perioperative outcome in patients with secondary mitral valve insufficiency

Jolanta Rzucidło-Resil1, Karolina Golińska-Grzybała1, Barbara Szlósarczyk2, Paweł Rostoff23, Andrzej Gackowski123, Grzegorz Gajos23, Bogusław Kapelak43, Jarosław Stoliński45
Pubmed: 37772356


Background: The aim of the study was to assess some parameters of right ventricle (RV) function as
predictors of short-term mortality in patients with severe secondary mitral regurgitation (SMR) after
mitral valve surgery.
Methods: We conducted a retrospective analysis of 112 consecutive patients with severe SMR who
had undergone mitral valve repair or replacement with or without concomitant coronary artery bypass
surgery. We assessed RV to pulmonary artery coupling by calculating the ratio of tricuspid annular
plane systolic excursion (TAPSE) to non-invasively estimated RV systolic pressure (RVSP). The study
endpoint was 30 days post-procedural mortality.
Results: Overall, the 30-day mortality was 6%. TAPSE/RVSP ratio < 0.42 mm/mmHg was a significant
predictor of mortality and remained so after adjusting for age and sex. The Kaplan-Meier survival
analysis showed that patients with RVSP > 55 mmHg and those with TAPSE/RVSP ratio < 0.42 mm/mmHg had a lower survival probability.
Conclusions: TAPSE/RVSP < 0.42 mm/mmHg is a strong predictor of short-term mortality in patients
with SMR when considered for valve surgery.

Article available in PDF format

View PDF Download PDF file


  1. Iung B, Baron G, Tornos P, et al. Valvular heart disease in the community: a European experience. Curr Probl Cardiol. 2007; 32(11): 609–661.
  2. Rzucidło-Resil J, Plicner D, Gackowski A, et al. Impact of the mechanism of mitral regurgitation on clinical outcomes in patients after mitral valve surgery. Kardiol Pol. 2019; 77(5): 525–534.
  3. Towheed A, Sabbagh E, Gupta R, et al. Right ventricular dysfunction and short-term outcomes following left-sided valvular surgery: an echocardiographic study. J Am Heart Assoc. 2021; 10(4): e016283.
  4. Baumgartner H, Falk V, Bax JJ, et al. ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017; 38(36): 2739–2791.
  5. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015; 28(1): 1–39.e14.
  6. Lancellotti P, Moura L, Pierard LA, et al. European Association of Echocardiography. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr. 2010; 11(4): 307–332.
  7. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010; 23(7): 685–713; quiz 786.
  8. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the american society of echocardiography developed in collaboration with the society for cardiovascular magnetic resonance. J Am Soc Echocardiogr. 2017; 30(4): 303–371.
  9. Chrustowicz A, Simonis G, Matschke K, et al. Right ventricular dilatation predicts survival after mitral valve repair in patients with impaired left ventricular systolic function. Eur J Echocardiogr. 2009; 10(2): 309–313.
  10. Di Mauro M, Calafiore AM, Penco M, et al. Mitral valve repair for dilated cardiomyopathy: predictive role of right ventricular dysfunction. Eur Heart J. 2007; 28(20): 2510–2516.
  11. Magne J, Girerd N, Sénéchal M, et al. Mitral repair versus replacement for ischemic mitral regurgitation: comparison of short-term and long-term survival. Circulation. 2009; 120(11 Suppl): S104–S111.
  12. Noack T, Marin Cuartas M, Kiefer P, et al. Isolated mitral valve repair in patients with reduced left ventricular ejection fraction. Ann Thorac Cardiovasc Surg. 2019; 25(6): 326–335.
  13. D'Agostino RS, Jacobs JP, Badhwar V, et al. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2019 Update on Outcomes and Quality. Ann Thorac Surg. 2019; 107(1): 24–32.
  14. Reisman AM, Thomas AT, Boateng P, et al. Predictors of 30-day outcomes following mitral valve repair. Ann Med Surg (Lond). 2019; 47: 5–12.
  15. Heikkinen J, Biancari F, Satta J, et al. Predictors of postoperative mortality after mitral valve repair: analysis of a series of 164 patients. Scand Cardiovasc J. 2005; 39(1-2): 71–77.
  16. Yun-Dan D, Wen-Jing Du, Xi-Jun X. Comparison of outcomes following mitral valve repair versus replacement for chronic ischemic mitral regurgitation: a meta-analysis. Thorac Cardiovasc Surg. 2017; 65(6): 432–441.
  17. Virk SA, Sriravindrarajah A, Dunn D, et al. A meta-analysis of mitral valve repair versus replacement for ischemic mitral regurgitation. Ann Cardiothorac Surg. 2015; 4(5): 400–410.
  18. Di Mauro M, Foschi M, Tancredi F, et al. Additive and independent prognostic role of abnormal right ventricle and pulmonary hypertension in mitral-tricuspid surgery. Int J Cardiol. 2018; 252: 39–43.
  19. Damy T, Viallet C, Lairez O, et al. Comparison of four right ventricular systolic echocardiographic parameters to predict adverse outcomes in chronic heart failure. Eur J Heart Fail. 2009; 11(9): 818–824.
  20. Haddad F, Couture P, Tousignant C, et al. The right ventricle in cardiac surgery, a perioperative perspective: II. Pathophysiology, clinical importance, and management. Anesth Analg. 2009; 108(2): 422–433.
  21. Borer JS, Hochreiter C, Rosen S. Right ventricular function in severe non-ischaemic mitral insufficiency. Eur Heart J. 1991; 12 (Suppl B): 22–25.
  22. Maslow AD, Regan MM, Panzica P, et al. Precardiopulmonary bypass right ventricular function is associated with poor outcome after coronary artery bypass grafting in patients with severe left ventricular systolic dysfunction. Anesth Analg. 2002; 95(6): 1507–1518.
  23. Nicolini F, Agostinelli A, Vezzani A, et al. Surgical treatment for functional ischemic mitral regurgitation: current options and future trends. Acta Biomed. 2015; 86(1): 17–26.
  24. Enter DH, Zaki A, Duncan BF, et al. A contemporary analysis of pulmonary hypertension in patients undergoing mitral valve surgery: Is this a risk factor? J Thorac Cardiovasc Surg. 2016; 151(5): 1288–1297.
  25. Thunberg CA, Gaitan BD, Grewal A, et al. Pulmonary hypertension in patients undergoing cardiac surgery: pathophysiology, perioperative management, and outcomes. J Cardiothorac Vasc Anesth. 2013; 27(3): 551–572.
  26. Ghoreishi M, Evans CF, DeFilippi CR, et al. Pulmonary hypertension adversely affects short- and long-term survival after mitral valve operation for mitral regurgitation: implications for timing of surgery. J Thorac Cardiovasc Surg. 2011; 142(6): 1439–1452.
  27. Vanderpool RR, Pinsky MR, Naeije R, et al. RV-pulmonary arterial coupling predicts outcome in patients referred for pulmonary hypertension. Heart. 2015; 101(1): 37–43.
  28. Tello K, Dalmer A, Axmann J, et al. Reserve of right ventricular-arterial coupling in the setting of chronic overload. Circ Heart Fail. 2019; 12(1): e005512.
  29. Guazzi M, Bandera F, Pelissero G, et al. Tricuspid annular plane systolic excursion and pulmonary arterial systolic pressure relationship in heart failure: an index of right ventricular contractile function and prognosis. Am J Physiol Heart Circ Physiol. 2013; 305(9): H1373–H1381.
  30. Trejo-Velasco B, Estevez-Loureiro R, Carrasco-Chinchilla F, et al. Prognostic role of TAPSE to PASP ratio in patients undergoing MitraClip procedure. J Clin Med. 2021; 10(5).
  31. Sultan I, Cardounel A, Abdelkarim I, et al. Right ventricle to pulmonary artery coupling in patients undergoing transcatheter aortic valve implantation. Heart. 2019; 105(2): 117–121.
  32. Tello K, Wan J, Dalmer A, et al. Validation of the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio for the assessment of right ventricular-arterial coupling in severe pulmonary hypertension. Circ Cardiovasc Imaging. 2019; 12(9): e009047.
  33. Guazzi M, Dixon D, Labate V, et al. RV contractile function and its coupling to pulmonary circulation in heart failure with preserved ejection fraction: stratification of clinical phenotypes and outcomes. JACC Cardiovasc Imaging. 2017; 10(10 Pt B): 1211–1221.