Exercise-induced RV-PA uncoupling predicted higher 1-year mortality and heart failure hospitalization in HF patients with secondary mitral regurgitation, unlike resting measures.
Does exercise-induced right ventricular to pulmonary artery uncoupling predict adverse outcomes in symptomatic heart failure patients with secondary mitral regurgitation?
Exercise-induced RV-PA uncoupling is a powerful predictor of 1-year adverse outcomes in HF patients with secondary mitral regurgitation, highlighting the prognostic value of exercise echocardiography.
Abstract Background Previous studies revealed that right ventricular to pulmonary artery (RV-PA) uncoupling is associated with an increased risk of death and heart failure (HF) hospitalizations in HF patients with secondary mitral regurgitation (SMR). Pulmonary hypertension is a known prognosticator of worse outcomes in this patient cohort. Assessment of echocardiography at rest often underestimates the full severity of the lesion, and exercise testing provides additional important prognostic information. In this regard, exercise-induced changes in SMR severity may lead to changes in pulmonary circulation and deteriorate RV function. The hemodynamic effects and prognostic importance of dynamic SMR concerning RV-PA coupling are still unknown. Methods Echocardiography was performed at rest and during isometric handgrip exercise following a standardized protocol in symptomatic HF patients with at least mild SMR at rest. According to the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/SPAP) ratio at rest and during exercise, patients were divided into tertiles. Patients were followed-up for 1-year to assess mortality, heart failure hospitalization and mitral valve (MV) surgery/interventions. Results A total of 151 HF patients (mean age 72.5±12.1 years; female 35.8%) were included. Mean TAPSE/SPAP at rest was 0.466±0.201 and 0.371±0.154 during exercise (p0.001). With decreasing TAPSE/SPAP ratio, patients were older, presented with worsened NYHA class, more often had atrial fibrillation, reduced renal function and increased NT-proBNP values. During exercise, patients in the 1. tertile had reduced left ventricular ejection fraction, increased right atrial volumes, decreased RV function, increased pulmonary pressures and more advanced tricuspid regurgitation compared to patients in the 2./3. tertile. The change in EROA from rest to exercise was associated with the change in TAPSE/SPAP ratio (r=-0.263; p=0.001). At rest RV-PA uncoupling was not associated with mortality/HF hospitalizations. Patients in the 1./2. tertile more often underwent MV surgery/intervention. Regarding exercise TAPSE/SPAP ratio, there was no difference in MV surgery/intervention rates. Patients in the 1. tertile showed increased mortality and HF hospitalization rates (Fig. 1). Conclusion Dynamic secondary mitral regurgitation during exercise testing was associated with a deterioration of right ventricular to pulmonary artery coupling. This translated into adverse clinical outcomes in heart failure patients with secondary mitral regurgitation, despite similar rates in mitral valve surgery/interventions. Advanced right ventricular dysfunction assessed by right ventricular to pulmonary artery uncoupling during exercise turned out as a powerful predictor of 1-year adverse outcomes. Thus, exercise testing might be a useful tool in symptomatic patients with suspicion of dynamic secondary mitral regurgitation to help guiding further therapeutic decision making.
Glasmacher et al. (2025) studied this question. Exercise-induced RV-PA uncoupling predicted higher 1-year mortality and heart failure hospitalization in HF patients with secondary mitral regurgitation, unlike resting measures.