Simpkin Charles T, Ivy D Dunbar, Friedberg Mark K, Burkett Dale A
Division of Cardiology, Heart Institute, Children's Hospital Colorado, Aurora (C.T.S., D.D.I., D.A.B.).
University of Colorado - Anschutz Medical Campus, Aurora (C.T.S., D.D.I., D.A.B.).
Circ Cardiovasc Imaging. 2024 Dec;17(12):e016882. doi: 10.1161/CIRCIMAGING.124.016882. Epub 2024 Dec 17.
Right ventricular-arterial coupling (RVAC) describes the relationship between right ventricular contractility and pulmonary vascular afterload. Noninvasive surrogates for RVAC using echocardiographic estimates of right ventricular function, such as tricuspid annular plane systolic excursion (TAPSE), have been shown to correlate with invasively measured RVAC and predict clinical outcomes in pediatric pulmonary arterial hypertension. However, given the limitations of TAPSE at accurately estimating right ventricular function in children, we hypothesized that a multivariable estimate of RVAC using right ventricular free-wall longitudinal strain (RVFW-LS) may perform better than those utilizing TAPSE at predicting clinical outcomes.
In all, 108 children from 2 institutions with pulmonary arterial hypertension underwent hemodynamic catheterization with simultaneous echocardiography. In a retrospective analysis, hybrid (echo and invasive) RVAC metrics included TAPSE/pulmonary vascular resistance (PVRi) and RVFW-LS/PVRi. Noninvasive echocardiographic metrics were TAPSE/echo-derived pulmonary artery systolic pressure (PASP) and RVFW-LS/PASP.
RVFW-LS correlated with PVRi (r=0.315, =0.01), though TAPSE did not (r=0.058, =0.64). PVRi, PASP, and RVAC metrics declined in patients with worse World Health Organization Functional Class (n=108), while TAPSE and RVFW-LS did not. PVRi, PASP, RVFW-LS/PVRi, TAPSE/PVRi, and RVFW-LS/PASP predicted the outcome variable of transplant or death (area under the curve, 0.771 [<0.001], 0.729 [=0.004], 0.748 [=0.002], 0.732 [=0.009], and 0.714 [=0.01], respectively), while TAPSE/PASP, RVFW-LS, and TAPSE did not (area under the curve, 0.671, 0.603, and 0.525, respectively). In patients without a history of repaired congenital heart disease (n=88), only RVFW-LS/PASP, PVRi, PASP, and RVFW-LS/PVRi predicted outcomes (area under the curve, 0.738 [=0.002], 0.729 [=0.01], 0.729 [=0.01], and 0.729 [=0.015], respectively).
In the pediatric population, baseline PVRi and echo-estimated PASP were strongly associated with adverse clinical outcomes, but TAPSE and RVFW-LS were not. Estimates of RVAC utilizing RVFW-LS were superior to those utilizing TAPSE-however, only marginally additive to PASP and PVRi at predicting the adverse clinical outcome in patients without a history of repaired congenital heart disease.
右心室-动脉耦联（RVAC）描述了右心室收缩力与肺血管后负荷之间的关系。使用超声心动图评估右心室功能的RVAC无创替代指标，如三尖瓣环平面收缩期位移（TAPSE），已被证明与有创测量的RVAC相关，并可预测小儿肺动脉高压的临床结局。然而，鉴于TAPSE在准确评估儿童右心室功能方面存在局限性，我们推测使用右心室游离壁纵向应变（RVFW-LS）对RVAC进行多变量评估在预测临床结局方面可能比使用TAPSE表现更好。
共有来自2家机构的108例患有肺动脉高压的儿童接受了血流动力学导管插入术并同步进行了超声心动图检查。在一项回顾性分析中，混合（超声心动图和有创）RVAC指标包括TAPSE/肺血管阻力（PVRi）和RVFW-LS/PVRi。无创超声心动图指标为TAPSE/超声心动图衍生的肺动脉收缩压（PASP）和RVFW-LS/PASP。
RVFW-LS与PVRi相关（r = 0.315，P = 0.01），而TAPSE则不然（r = 0.058，P = 0.64）。在世界卫生组织功能分级较差的患者（n = 108）中，PVRi、PASP和RVAC指标下降，而TAPSE和RVFW-LS则没有。PVRi、PASP、RVFW-LS/PVRi、TAPSE/PVRi和RVFW-LS/PASP预测了移植或死亡的结局变量（曲线下面积分别为0.771 [<0.001]、0.729 [P = 0.004]、0.748 [P = 0.002]、0.732 [P = 0.009]和0.714 [P = 0.01]），而TAPSE/PASP、RVFW-LS和TAPSE则不然（曲线下面积分别为0.671、0.603和0.525）。在没有先天性心脏病修复史的患者（n = 88）中，只有RVFW-LS/PASP、PVRi、PASP和RVFW-LS/PVRi预测了结局（曲线下面积分别为0.738 [P = 0.002]、0.729 [P = 0.01]、0.729 [P = 0.01]和0.729 [P = 0.015]）。
在儿科人群中，基线PVRi和超声心动图估计的PASP与不良临床结局密切相关，但TAPSE和RVFW-LS则不然。使用RVFW-LS对RVAC的评估优于使用TAPSE的评估——然而，在预测没有先天性心脏病修复史的患者的不良临床结局方面，仅比PASP和PVRi略有增加。
