Tricuspid Annulus Excursion in Heart Failure
abstract & commentary
Synopsis: Tricuspid annular plane systolic excursion (TAPSE) adds prognostic information to NYHA class, LVEF, and E deceleration time in patients with congestive heart failure due to LV systolic dysfunction.
Source: Ghio S, et al. Am J Cardiol 2000;85:837-842.
Reduced right ventricular function indicates a worse prognosis in patients with congestive heart failure due to left ventricular dysfunction. Radionuclide and two-dimensional echo right ventricle (RV) volume estimates are problematic in many patients, thus Ghio and colleagues assessed the value of tricuspid annular plane systolic excursion (TAPSE) and Doppler mitral valve filling parameters for their predictive value in 140 heart failure patients. All had LV ejection fraction of less than 35% and were on maximum medical therapy. There were 94 with dilated cardiomyopathy and 46 with ischemic cardiomyopathy. Patients in NYHA class IV were eliminated. All patients had right heart catheterization to determine thermodilution RV ejection fraction, which was used as the gold standard for RV systolic function. Within an hour of catheterization, echocardiography was performed and the following parameters were measured: mitral Doppler E deceleration, RV areas in the four-chamber apical view, transverse RV axis diameters, and TAPSE. TAPSE was measured from an m-mode of the lateral tricuspid annulus in the four-chamber view. Three measurements correlated significantly with RVEF: RV area change (r = 0.69), RV diameter change (r = 0.68), and TAPSE (r = 0.62). After a mean follow-up of 24 months, there were 45 deaths (22 sudden) and seven patients underwent transplantation. Multivariant analysis showed that NYHA class III (hazard ratio = 4) and TAPSE higher than 14 mm (HR = 3) were independently predictive of death or transplantation. Only 97 patients had adequate Doppler data for analysis. Among these patients, E deceleration less than 125 ms and LVEF less than 20% also added to the predictive model. Ghio et al conclude that TAPSE adds prognostic information to NYHA class, LVEF, and E deceleration time in patients with congestive heart failure due to LV systolic dysfunction. Also, TAPSE is easy to obtain even in patients in atrial fibrillation and tachycardia when mitral Doppler parameters are not measurable.
Comment by Michael H. Crawford, MD
Although several studies have shown the prognostic value of RV function in heart failure patients, RV systolic function is difficult to obtain. RV function measures by radionuclide techniques are hampered by overlap of other structures, tricuspid regurgitation, and the expense of these studies. Echocardiographic estimates of RV volumes is difficult because of the complex geometry of the RV, which measurements in one plane do not consider. Doppler approaches are limited in this population, as this study illustrates (possible in two-thirds). Thus, TAPSE is an attractive surrogate for RV function that is easy to obtain in almost all patients. Also, in this study it was superior to many traditional measures of prognosis in heart failure patients. The reason for this excellent performance is not clear from this study, but may be related to the excellent reproducibility shown in this study or that the long axis excursion of the RV is most reflective of overall performance. The reason RV function is of prognostic value in heart failure may be multifactorial and different in each patient. In some, it may reflect pulmonary hypertension from severe LV dysfunction. In others, it may reflect a severe diffuse myocardial process. Regardless of the mechanism, RV function is of prognostic value in heart failure patients and TAPSE is an easy way to assess it.
The most easily obtained measure of RV function of prognostic value in heart failure patients is:
a. tricuspid annular plane systolic excursion.
b. mitral E deceleration.
c. RV area change.
d. RV diameter change.
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