Effects of Sacubitril/Valsartan on the Right Ventricular Arterial Coupling in Patients with Heart Failure with Reduced Ejection Fraction

Application of an echocardiographic index to characterize right ventricular-pulmonary arterial coupling in heart failure

Heart failure (HF), with its high morbidity and mortality, remains a global public health issue. Right ventricular (RV) dysfunction is a sign of deterioration in the natural history of HF, and a thorough evaluation of the relationship between RV contractility and its afterload through RV-pulmonary arterial (RV-PA) coupling can aid in accurately assessing overall RV function. The ratio of RV end-systolic elastance (Ees) to pulmonary arterial elastance (Ea) invasively measured by right heart catheterization served as the gold standard for evaluating RV-PA coupling. An echocardiographic index termed tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) has been shown to correlate well with Ees/Ea. TAPSE/PASP is recognized as a non-invasive surrogate of RV-PA coupling and has been extensively studied in patients with HF. This review briefly describes the methods of assessing RV-PA coupling, mainly discussing echocardiography, summarizes the clinical utility of TAPSE/PASP in patients with different HF types, and provides an overview of the available literature.

Impact of angiotensin receptor-neprilysin inhibition (ARNI) in improving ejection fraction and left and right ventricular remodeling in heart failure

Angiotensin receptor neprilysin inhibitors (ARNI), a new therapeutic class of agents acting on the renin angiotensin aldosterone system (RAAS) and neutral endopeptidase system has been developed in treatment of ventricular remodeling and has attracted considerable attention. The first in class is LCZ696, which is a molecule that combines Valsartan (ARB) and Sacubitril (neprilysin inhibitor) within a single substance. Sacubitril-Valsartan is the first angiotensin receptor enkephalin inhibitors (ARNI), which can block angiotensin II type 1 receptor (AT1R) while inhibiting enkephalin (NEP) and effectively reverse ventricular remodeling in heart failure patients. It has been recommended by the European and American authoritative guidelines on heart failure as Class I for the treatment of chronic heart failure particularly as intensive care medicine. Sacubitril-Valsartan demonstrated significant effects in improving left ventricular performance and remodeling in patients with heart failure with reduced ejection fraction. Sacubitril acts on increased levels of circulating natriuretic peptides by preventing their enzymatic breakdown and Valsartan, which acts to lessen the effects of the RAAS. However, not more research has been done on its effects on the right ventricle remodeling. This review aimed to assess the impact of angiotensin receptor neprilysin inhibitors on left and right ventricular remodeling in heart failure patients.

Effect of sacubitril valsartan on heart failure with mid-range or preserved ejection fraction in patients on maintenance hemodialysis: real-world experience in a single-center, prospective study

BACKGROUND

This study aimed to evaluate the effect of sacubitril valsartan (SV) on heart failure (HF) hospitalization and cardiovascular mortality in patients on hemodialysis with HF with preserved ejection fraction (EF; HFpEF).

METHODS

This single-center, prospective study enrolled 155 stable hemodialysis patients with EF > 40% who were followed up for 12 months. Fifty-nine patients were treated with SV; the others were matched for EF (57.89 ± 9.35 vs. 58.00 ± 11.82, P = 0.9) at a ratio of 1:1 and included as controls. The target dosage of SV was 200 mg/day.

RESULTS

Twenty-three (23/155; 14.84%) had HF with mid-range EF (HFmrEF), while 132 (85.16%) had HFpEF. After SV treatment, the peak early diastolic transmitral flow velocity/peak early diastolic mitral annular tissue velocity(E/e') improved from 17.19 ± 8.74 to 12.80 ± 5.52 (P = 0.006), the left ventricular (LV) end-diastolic diameter decreased from 53.14 ± 7.67 mm to 51.56 ± 7.44 mm (P = 0.03), and the LV mass index decreased from 165.7 ± 44.6 g/m2 to 154.8 ± 24.0 g/m2 (P = 0.02). LVEF (P = 0.08) and LV global longitudinal strain (P = 0.7) did not change significantly. The composite outcome of first and recurrent HF hospitalization or cardiovascular death showed no difference between group. However, the Acute Dialysis Quality Initiative Workgroup (ADQI) HF class improved in 39 and 15 patients and worsened in 1 and 11 patients in the SV and control groups, respectively (P < 0.001). Age, diabetes mellitus, and pulmonary arterial pressure were independent risk factors for HF hospitalization and cardiovascular mortality in patients with HFpEF.

CONCLUSIONS

SV improved LV hypertrophy, diastolic function, and the ADQI class for HF; however, it failed to reduce the composite endpoints of HF hospitalization and cardiovascular disease-related mortality over 12 months of follow-up in patients on maintenance hemodialysis with EF of > 40%.

Prognostic Role of Right Ventricular-Pulmonary Artery Coupling Assessed by TAPSE/PASP Ratio in Patients With Acute Heart Failure

BACKGROUND

Right ventricular (RV) dysfunction is a significant risk of major adverse cardiac events in patients with acute heart failure (AHF). In this study, we evaluated RV-pulmonary artery (PA) coupling, assessed by tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) and assessed its prognostic significance, in AHF patients.

METHODS

We measured the TAPSE/PASP ratio and analyzed its correlations with other echocardiographic parameters. Additionally, we assessed its prognostic role in AHF patients.

RESULTS

A total of 1147 patients were included in the analysis (575 men, aged 70.81 ± 13.56 years). TAPSE/PASP ratio exhibited significant correlations with left ventricular (LV) ejection fraction(r = 0.243, p < 0.001), left atrial (LA) diameter(r = -0.320, p < 0.001), left atrial global longitudinal strain (LAGLS, r = 0.496, p < 0.001), mitral E/E' ratio(r = -0.337, p < 0.001), and right ventricular fractional area change (RVFAC, r = 0.496, p < 0.001). During the median follow-up duration of 29.0 months, a total of 387 patients (33.7%) died. In the univariate analysis, PASP, TAPSE, and TAPSE/PASP ratio were significant predictors of mortality. After the multivariate analysis, TAPSE/PASP ratio remained a statistically significant parameter for all-cause mortality (hazard ratio [HR], 0.453; p = 0.037) after adjusting for other parameters. In the receiver operating curve analysis, the optimal cut-off level of TAPSE/PASP ratio for predicting mortality was 0.33 (area under the curve = 0.576, p < 0.001), with a sensitivity of 65% and a specificity of 47%. TAPSE/PASP ratio < 0.33 was associated with an increased risk of mortality after adjusting for other variables (HR, 1.306; p = 0.025).

CONCLUSIONS

In AHF patients, TAPSE/PASP ratio demonstrated significant associations with RVFAC, LA diameter and LAGLS. Moreover, a decreased TAPSE/PASP ratio < 0.33 was identified as a poor prognostic factor for mortality.

Long-Term Effects of Sacubitril-Valsartan on Cardiac Remodeling: A Parallel Echocardiographic Study of Left and Right Heart Adaptive Response

Sacubitril/Valsartan (S/V) carries potential anti-remodeling properties, however long-term effects and biventricular adaptive response are poorly described. 76 HFrEF patients who underwent progressive uptitration of S/V, completed the annual scheduled follow-up. After a median follow-up of 11 (8-13) months, left ventricular (LV) reverse remodeling (RR) is defined as (1) absolute increase in LV ejection fraction (EF) ≥ 10% or LVEF ≥ 50% at follow-up and (2) decrease in indexed LV end-diastolic diameter (LVEDDi) of at least 10% or indexed LVEDDi ≤ 33 mm/m2, occurred in 27.6%. Non-ischemic etiology, shorter duration of HF, and absence of a history of AF were independently associated with LVRR (p < 0.05). TAPSE and TAPSE/PASP, a non-invasive index of right ventricular (RV) coupling to the pulmonary circulation, significantly improved at follow-up (0.45 vs. 0.56, p = 0.02). 41% of patients with baseline RV dysfunction obtained favorable RV remodeling despite only a moderate correlation between RV and LV function was observed (r = 0.478, p = 0.002). Our data point to a potential long-term reverse global remodeling effect by S/V, especially in patients who start S/V at an early stage of the disease, and focus our attention on a possible direct effect of the drug in synergistic hemodynamics between RV and pulmonary circulation.

Adaptive versus maladaptive right ventricular remodelling

Right ventricular (RV) function and its adaptation to increased afterload [RV-pulmonary arterial (PA) coupling] are crucial in various types of pulmonary hypertension, determining symptomatology and outcome. In the course of disease progression and increasing afterload, the right ventricle undergoes adaptive remodelling to maintain right-sided cardiac output by increasing contractility. Exhaustion of compensatory RV remodelling (RV-PA uncoupling) finally leads to maladaptation and increase of cardiac volumes, resulting in heart failure. The gold-standard measurement of RV-PA coupling is the ratio of contractility [end-systolic elastance (Ees)] to afterload [arterial elastance (Ea)] derived from RV pressure-volume loops obtained by conductance catheterization. The optimal Ees/Ea ratio is between 1.5 and 2.0. RV-PA coupling in pulmonary hypertension has considerable reserve; the Ees/Ea threshold at which uncoupling occurs is estimated to be ~0.7. As RV conductance catheterization is invasive, complex, and not widely available, multiple non-invasive echocardiographic surrogates for Ees/Ea have been investigated. One of the first described and best validated surrogates is the ratio of tricuspid annular plane systolic excursion to estimated pulmonary arterial systolic pressure (TAPSE/PASP), which has shown prognostic relevance in left-sided heart failure and precapillary pulmonary hypertension. Other RV-PA coupling surrogates have been formed by replacing TAPSE with different echocardiographic measures of RV contractility, such as peak systolic tissue velocity of the lateral tricuspid annulus (S'), RV fractional area change, speckle tracking-based RV free wall longitudinal strain and global longitudinal strain, and three-dimensional RV ejection fraction. PASP-independent surrogates have also been studied, including the ratios S'/RV end-systolic area index, RV area change/RV end-systolic area, and stroke volume/end-systolic volume. Limitations of these non-invasive surrogates include the influence of severe tricuspid regurgitation (which can cause distortion of longitudinal measurements and underestimation of PASP) and the angle dependence of TAPSE and PASP. Detection of early RV remodelling may require isolated analysis of single components of RV shortening along the radial and anteroposterior axes as well as the longitudinal axis. Multiple non-invasive methods may need to be applied depending on the level of RV dysfunction. This review explains the mechanisms of RV (mal)adaptation to its load, describes the invasive assessment of RV-PA coupling, and provides an overview of studies of non-invasive surrogate parameters, highlighting recently published works in this field. Further large-scale prospective studies including gold-standard validation are needed, as most studies to date had a retrospective, single-centre design with a small number of participants, and validation against gold-standard Ees/Ea was rarely performed.

Molecular mechanisms of sacubitril/valsartan in cardiac remodeling

Cardiovascular diseases have become a major clinical burden globally. Heart failure is one of the diseases that commonly emanates from progressive uncontrolled hypertension. This gives rise to the need for a new treatment for the disease. Sacubitril/valsartan is a new drug combination that has been approved for patients with heart failure. This review aims to detail the mechanism of action for sacubitril/valsartan in cardiac remodeling, a cellular and molecular process that occurs during the development of heart failure. Accumulating evidence has unveiled the cardioprotective effects of sacubitril/valsartan on cellular and molecular modulation in cardiac remodeling, with recent large-scale randomized clinical trials confirming its supremacy over other traditional heart failure treatments. However, its molecular mechanism of action in cardiac remodeling remains obscure. Therefore, comprehending the molecular mechanism of action of sacubitril/valsartan could help future research to study the drug's potential therapy to reduce the severity of heart failure.

The comparative effects of sacubitril/valsartan versus enalapril on pulmonary hypertension due to heart failure with a reduced ejection fraction

The purpose of this study was to investigate the effects of sacubitril/valsartan on right ventricular (RV) function in patients with pulmonary hypertension (PH) due to heart failure with reduced ejection fraction (HFrEF). We prospectively enrolled patients with HFrEF-induced PH admitted to the Department of Cardiology between August 2018 and December 2019. Patients were randomized to receive oral treatment with sacubitril/valsartan or enalapril. Epidemiological data were recorded before treatment. Echocardiography was performed at admission and 6 months of follow-up, and all parameters were compared. Major adverse cardiac events (MACEs) were compared between baseline and 6 months follow-up. There were no significant differences in the baseline characteristics between the two groups. After 6 months of treatment, both treatment groups improved the following parameters from baseline (mean ± SD): left atrium, left ventricle, the left ventricular ejection function (LVEF), RV systolic function (the tricuspid annular plane systolic excursion [TAPSE], the systolic pulmonary artery pressure [sPAP], and TAPSE/sPAP). After 6 months, sacubitril/valsartan improved significantly the following parameters compared with enalapril (all p < 0.05): LVEF (47.07 ± 6.93% vs. 43.47 ± 7.95%); TAPSE (15.33 ± 1.31 vs. 14.78 ± 1.36 mm); sPAP (36.76 ± 14.32 vs. 42.26 ± 12.07 mmHg); and TAPSE/sPAP ratio (0.50 ± 0.23 vs. 0.39 ± 0.14), respectively. There was no difference in readmissions due to recurrent heart failure. Sacubitril/valsartan seems to provide more beneficial effects among patients with HFrEF-induced PH to improve RV function, along with a decrease in pulmonary pressure.

Predictors of sacubitril/valsartan high dose tolerability in a real world population with HFrEF

AIMS

The angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril/valsartan (Sac/Val) demonstrated to be superior to enalapril in reducing hospitalizations, cardiovascular and all-cause mortality in patients with ambulatory heart failure and reduced ejection fraction (HFrEF), in particular when it is maximally up-titrated. Unfortunately, the target dose is achieved in less than 50% of HFrEF patients, thus undermining the beneficial effects on the outcomes. In this study, we aimed to evaluate the role of Sac/Val and its titration dose on reverse cardiac remodelling and determine which echocardiographic index best predicts the up-titration success.

METHODS AND RESULTS

From January 2020 to June 2021, we retrospectively identified 95 patients (65.6 [59.1-72.8] years; 15.8% females) with chronic HFrEF who were prescribed Sac/Val from the HF Clinics of 5 Italian University Hospitals and evaluated the tolerability of Sac/Val high dose (the ability of the patient to achieve and stably tolerate the maximum dose) as the primary endpoint in the cohort. We used a multivariable logistic regression analysis, with a stepwise backward selection method, to determine the independent predictors of Sac/Val maximum dose tolerability, using, as candidate predictors, only variables with a P-value < 0.1 in the univariate analyses. Candidate predictors identified for the multivariable backward logistic regression analysis were age, sex, body mass index (BMI), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), dyslipidaemia, atrial fibrillation, systolic blood pressure (SBP), baseline tolerability of ACEi/ARBs maximum dose, left ventricle global longitudinal strain (LVgLS), LV ejection fraction (EF), tricuspid annulus plane systolic excursion (TAPSE), right ventricle (RV) fractional area change (FAC), RV global and free wall longitudinal strain (RVgLS and RV-FW-LS). After the multivariable analysis, only one categorical (ACEi/ARBs maximum dose at baseline) and three continuous (younger age, higher SBP, and higher TAPSE), resulted significantly associated with the study outcome variable with a strong discriminatory capacity (area under the curve 0.874, 95% confidence interval (CI) (0.794-0.954) to predict maximum Sac/Val dose tolerability.

CONCLUSIONS

Our study is the first to analyse the potential role of echocardiography and, in particular, of RV dysfunction, measured by TAPSE, in predicting Sac/Val maximum dose tolerability. Therefore, patients with RV dysfunction (baseline TAPSE <16 mm, in our cohort) might benefit from a different strategy to titrate Sac/Val, such as starting from the lowest dose and/or waiting for a more extended period of observation before attempting with the higher doses.

Prognostic Implications of Right Ventricular Free Wall Strain in Recipients of Cardiac Resynchronization Therapy

Right ventricular (RV) function is an important prognostic marker in cardiac resynchronization therapy (CRT) recipients. Measuring RV systolic function with echocardiography, however, remains challenging due to the complexity of right heart morphology. Evaluation of RV function with RV free wall strain (FWS) may improve risk stratification in recipients of CRT compared with conventional RV function parameters. In 871 recipients of CRT (mean age 65 ± 11 years, 75% were men), RV function was assessed by RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and RV FWS measured by speckle tracking echocardiography. RV dysfunction was defined as RV FWS <23%, RV FAC <35%, and TAPSE <17 mm according to present guidelines. Patients were followed up for the primary end point of all-cause mortality. RV FWS identified a higher percentage of patients with RV systolic dysfunction (80.6%) in comparison with RV FAC (44.1%) and TAPSE (60.6%). During a median follow-up of 97 (53 to 145) months, 521 patients (59.8%) died. Recipients of CRT with RV FWS <23% had higher event rates than those with RV FWS ≥23% (p <0.001). On multivariable analysis, RV FWS <23% was independently associated with all-cause mortality (hazard ratio 1.618; 95% confidence interval 1.252 to 2.092; p <0.001) and demonstrated incremental prognostic value over baseline clinical parameters as well as conventional RV function parameters. In conclusion, RV FWS is more sensitive than conventional echocardiographic markers of RV function in detecting impaired RV function. RV FWS is independently associated with all-cause mortality and demonstrates incremental prognostic value over conventional RV function parameters in recipients of CRT.

Effect of Sacubitril/Valsartan on the Right Ventricular Function and Pulmonary Hypertension in Patients With Heart Failure With Reduced Ejection Fraction: A Systematic Review and Meta-Analysis of Observational Studies

Background

Sacubitril/valsartan (S/V) demonstrated significant effects in improving left ventricular performance and remodeling in patients with heart failure with reduced ejection fraction. However, its effects on the right ventricle remain unclear. This systematic review and meta‐analysis aimed to assess the impact of S/V on right ventricular function and pulmonary hypertension.

Methods and Results

We searched PubMed, Embase, Cochrane Library, and Web of Science from January 2010 to April 2021 for studies reporting right ventricular and pulmonary pressure indexes following S/V treatment. The quality of included studies was assessed using the Newcastle‐Ottawa scale. Variables were pooled using a random‐effects model to estimate weighted mean differences with 95% CIs. We identified 10 eligible studies comprising 875 patients with heart failure with reduced ejection fraction (mean age, 62.2 years; 74.0% men), all of which were observational. Significant improvements on right ventricular function and pulmonary hypertension after S/V initiation were observed, including tricuspid annular plane systolic excursion (weighted mean difference, 1.26 mm; 95% CI, 0.33–2.18 mm; P=0.008), tricuspid annular peak systolic velocity (weighted mean difference, 0.85 cm/s; 95% CI, 0.25–1.45 cm/s; P=0.005), and systolic pulmonary arterial pressure (weighted mean difference, 7.21 mm Hg; 95% CI, 5.38–9.03 mm Hg; P<0.001). Besides, S/V had a significant beneficial impact on left heart function, which was consistent with previous studies. The quadratic regression model revealed a certain correlation between tricuspid annular plane systolic excursion and left ventricular ejection fraction after excluding the inappropriate data (P=0.026).

Conclusions

This meta‐analysis verified that S/V could improve right ventricular performance and pulmonary hypertension in heart failure with reduced ejection fraction, which did not seem to be fully dependent on the reverse remodeling of left ventricle.

Registration

URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42021247970.

Sacubitril/Valsartan in the Treatment of Right Ventricular Dysfunction in Patients With Heart Failure With Reduced Ejection Fraction: A Real-world Study

OBJECTIVE

There is increasing evidence supporting the efficacy of sacubitril/valsartan for treating left heart failure, but few studies have investigated its effects on right ventricular (RV) dysfunction. This study aimed to explore the effects of sacubitril/valsartan on RV dysfunction among patients with heart failure with reduced ejection fraction (HFrEF).

METHODS

A total of 93 patients with HFrEF with RV dysfunction who were hospitalized from January 2018 through June 2019 were included in this retrospective observational study. All patients received their first sacubitril/valsartan treatment as in patients during the study period. We excluded 11 patients who were lost to follow-up or had incomplete heart echocardiography data. After 6 months of follow-up, we re-evaluated New York Heart Association Functional Classification and performed echocardiography to identify changes in relevant variables after treatment.

RESULTS

At baseline, 24% of the patients had an initial sacubitril/valsartan regimen of 12/13 mg twice daily and 76% of the patients had an initial dose of 24/26 mg twice daily. During follow-up, 27% of patients increased their dosage to 49/50 mg twice daily, 68% of patients were taking 24/26 mg twice daily, and 5% of the patients were still taking 12/13 mg twice daily. We found that sacubitril/valsartan treatment was associated with significant improvements in the following RV function indicators: tricuspid annular plane systolic excursion, tricuspid annular s' peak velocity (S'), RV fractional area change, and pulmonary artery systolic pressure (PASP). Crude linear regression analysis revealed that a tricuspid annular plane systolic excursion improvement was positively correlated with a change in left ventricular ejection fraction (LVEF) and negatively correlated with a change in left ventricular end-systolic volume (LVESV). However, these correlations were nonexistent after adjusting for multiple echocardiographic variables.

CONCLUSIONS

In patients with RV dysfunction and HFrEF, sacubitril/valsartan may improve RV remodeling. This influence may be independent of left cardiac remodeling.

Predictors of right ventricular function improvement with sacubitril/valsartan in a real-life population of patients with chronic heart failure

Background

Observational studies have demonstrated that treatment with sacubitril/valsartan may improve left ventricular (LV) systolic and diastolic function in subjects with reduced LV ejection fraction (LVEF) in real‐world studies. Subjects with heart failure and reduced EF (HFrEF), however, are also characterized by an impaired right ventricular (RV) function. We therefore aimed to evaluate whether also RV function may improve after S/V therapy and possible predictors of RV improvement could be identified at echocardiography and tissue Doppler imaging.

Methods

Fifty consecutive patients (67 ± 8 years, LVEF 28 ± 6%, male 86%) with chronic HFrEF and NYHA class II‐III were followed up for 6 months after therapy with S/V. LV&RV function was assessed at baseline and after 6 months of therapy.

Results

After 6‐month therapy with S/V a significant improvement was shown in the following echocardiography parameters assessing RV function: PAsP (31 ± 11 vs. 35 ± 10 mmHg, p < 0.001), TAPSE (19 ± 3 vs. 18 ± 3 mm, p < 0.001), RV FAC (38 ± 7 vs. 34 ± 6 mm, p < 0.001), RV S’ (12 ± 2 vs. 10 ± 2 cm/s, p < 0.001), RV‐FW‐LS (−20 ± 5 vs. −18 ± 5%, p < 0.001), RV‐4Ch‐LS (−16 ± 5 vs. −14 ± 5%, p < 0.001). At multivariable analysis improvement in RV‐FW‐LS was associated to baseline levels of RV S’ (r 0.75, p < 0.01) and RAV (r –0.32, p < 0.05).

Conclusions

In a real‐world scenario, 6‐month therapy with S/V was associated with an improved RV function in HFrEF. RV function improvement may be predicted by assessing baseline RV S’ and right atrial volume values.

Sacubitril-valsartan initiation in chronic heart failure patients impacts sleep apnea: the ENTRESTO-SAS study

Aims

Optimizing medical cardiac treatment for sleep apnoea (SA) in patients with chronic heart failure and reduced ejection fraction (HFrEF) is an expert Grade C recommendation based on six studies encompassing a total of 67 patients only. Whether sacubitril–valsartan (SV), a cornerstone of HFrEF medical treatment, impacts SA is unknown and requires evaluation.

Methods and results

The ENTRESTO‐SAS trial is a six‐centre, prospective, open‐label real‐life cohort study (NCT02916160). Ambulatory patients eligible for SV (i.e. HFrEF adults who remain symptomatic despite optimal treatment) were evaluated before and after 3 months of SV (including nocturnal ventilatory polygraphy); 118 patients were final analysed [median age was 66 (IQ_25–75: 56–73) years, 81.4% male, 36.5% New York Heart Association III–IV, N‐terminal pro‐B‐type natriuretic peptide level of 1564 (701–3376) ng/L, left ventricular ejection fraction of 30 (25–34)%, 60.7% ischaemic HFrEF, 97.5% initially treated with angiotensin‐converting enzyme inhibitors or angiotensin II receptor blockers, 83.9% with beta‐blockers, 64.4% with mineralocorticoid receptor antagonists, and 74.6% with diuretics]. Three groups were defined according to initial central/obstructive apnoea–hypopnoea indices (AHIs): G1 (n = 49, AHI_central ≥ 5/h and AHI_obstructive < 15/h); G2 (n = 27, AHI_obstructive ≥ 15/h); and G3 (n = 42, AHI_central < 5/h and AHI_obstructive < 15/h). At 3 months, the AHI (main predefined outcome) decreased significantly by −7.10/h (IQ_25–75: −16.10 to 0.40; P < 0.001) in G1 + G2 without positive airway pressure treatment (45 patients, median initial AHI of 24.20 (IQ_25–75: 16.40–43.50)/h). Of these, 24.4% presented an AHI decrease ≥50% and 37.78% had a final AHI < 15/h (tendency for improvement from an initial value of 20%: P = 0.0574). For G1 patients (n = 37), AHI significantly decreased from a median of 22.90 (16.00–43.50)/h to 19.20 (12.70–31.10)/h (P = 0.002). For G2 patients (n = 8), AHI decreased from a median of 30.10 (26.40–47.60)/h to 22.75 (14.60–36.90)/h (statistically non‐significant, P = 0.059).

Conclusions

In this real‐life population, SV treatment for 3 months in SA patients is associated with a significant decrease in AHI. These results support the current guidelines that recommend first an optimization of the HFrEF treatment in patients with HFrEF and central SA. A potential positive airway pressure sparing effect merits further investigation.

Prognostic Role of TAPSE to PASP Ratio in Patients Undergoing MitraClip Procedure

Background: Transcatheter mitral valve repair (TMVR) is an effective therapy for high-risk patients with severe mitral regurgitation (MR) but heart failure (HF) readmissions and death remain substantial on mid-term follow-up. Recently, right ventricular (RV) to pulmonary arterial (PA) coupling has emerged as a relevant prognostic predictor in HF. In this study, we aimed to assess the prognostic value of tricuspid annular plane systolic excursion (TAPSE) to PA systolic pressure (PASP) ratio as a non-invasive measure of RV-to-PA coupling in patients undergoing TMVR with MitraClip (Abbott, CA, USA). Methods: Multicentre registry including 228 consecutive patients that underwent successful TMVR with MitraClip. The sample was divided in two groups according to TAPSE/PASP median value: 0.35. The primary combined endpoint encompassed HF readmissions and all-cause mortality. Results: Mean age was 72.5 ± 11.5 years and 154 (67.5%) patients were male. HF readmissions and all-cause mortality were more frequent in patients with TAPSE/PASP ≤ 0.35: Log-Rank 8.844, p = 0.003. On Cox regression, TAPSE/PASP emerged as a prognostic predictor of the primary combined endpoint, together with STS-Score. TAPSE/PASP was a better prognostic predictor than either TAPSE or PASP separately. Conclusions: TAPSE/PASP ratio appears as a novel prognostic predictor in patients undergoing MitraClip implantation that might improve risk stratification and candidate selection.