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Linking Energetic Inefficiency to Ventriculoarterial Uncoupling in Pulmonary Hypertension

Venkateshvaran, Ashwin LU orcid ; Lindow, Thomas LU ; Jumatate, Raluca LU ; Kovacs, Attila L. ; Ingvarsson, Annika LU orcid ; Lindqvist, Per and Werther Evaldsson, Anna LU orcid (2026) In Echocardiography 43(1). p.1-2
Abstract
Background
Right ventricular–pulmonary arterial (RV–PA) uncoupling is central to prognosis in precapillary pulmonary hypertension (PH). While the tricuspid annular plane systolic excursion tosystolic pulmonary artery pressure (TAPSE/sPAP) ratio is an established bedside surrogate of RV–PA coupling, novel energetic markers such as three-dimensional (3D)–derived right ventricular (RV) global wasted work (GWW) may provide complementary insight into maladaptive RV remodeling.

Objectives
To contextualize the prognostic value of RV GWW relative to TAPSE/sPAP and clarify their mechanistic and clinical complementarity.

Methods and Results
Patients with elevated GWW (≥38 mmHg/%) exhibited evidence of RV–PA uncoupling,... (More)
Background
Right ventricular–pulmonary arterial (RV–PA) uncoupling is central to prognosis in precapillary pulmonary hypertension (PH). While the tricuspid annular plane systolic excursion tosystolic pulmonary artery pressure (TAPSE/sPAP) ratio is an established bedside surrogate of RV–PA coupling, novel energetic markers such as three-dimensional (3D)–derived right ventricular (RV) global wasted work (GWW) may provide complementary insight into maladaptive RV remodeling.

Objectives
To contextualize the prognostic value of RV GWW relative to TAPSE/sPAP and clarify their mechanistic and clinical complementarity.

Methods and Results
Patients with elevated GWW (≥38 mmHg/%) exhibited evidence of RV–PA uncoupling, including a reduced RV end-systolic elastance to arterial elastance (Ees/Ea) ratio (0.47 [0.34–0.73] vs. 0.71 [0.50–0.91]; p = 0.007) and lower TAPSE/sPAP ratio (0.21 [0.18–0.32] vs. 0.34 [0.22– 0.45] mm/Hg; p = 0.003) compared with lower GWW. In secondary analyses, a TAPSE/sPAP ratio below the median was associated with increased risk of death or lung transplantation (hazard ratio [HR] 3.20; 95% CI: 1.45–7.08), remaining significant after adjustment for age and sex (adjusted HR 2.97; 95% CI: 1.27–6.94). Discrimination was modest and comparable for TAPSE/sPAP (C-statistic 0.63; 95% CI: 0.53–0.73) and GWW (C-statistic 0.61), with no significant difference between metrics (ΔC = −0.02; p = 0.68).

Conclusions
TAPSE/sPAP remains a robust and clinically valuable surrogate of macroscopic RV–PA coupling. However, GWW offers complementary information by quantifying myocardial inefficiency related to paradoxical and postsystolic deformation, capturing energetic consequences of afterload mismatch that may not be reflected by displacement-based indices alone. Integrating energetic and mechanical markers may enable a more granular assessment of RV performance, particularly in intermediate-risk PH, and warrants evaluation in larger multicenter studies. (Less)
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author
; ; ; ; ; and
organization
publishing date
type
Contribution to journal
publication status
published
subject
in
Echocardiography
volume
43
issue
1
article number
e70389
pages
1 - 2
publisher
John Wiley & Sons Inc.
external identifiers
  • pmid:41498567
  • scopus:105026840504
ISSN
0742-2822
DOI
10.1111/echo.70389
language
English
LU publication?
yes
id
f84b70ca-ab2c-4fd9-8c55-6e1b85b72816
date added to LUP
2026-01-30 15:17:58
date last changed
2026-02-02 08:15:44
@misc{f84b70ca-ab2c-4fd9-8c55-6e1b85b72816,
  abstract     = {{Background<br/>Right ventricular–pulmonary arterial (RV–PA) uncoupling is central to prognosis in precapillary pulmonary hypertension (PH). While the tricuspid annular plane systolic excursion tosystolic pulmonary artery pressure (TAPSE/sPAP) ratio is an established bedside surrogate of RV–PA coupling, novel energetic markers such as three-dimensional (3D)–derived right ventricular (RV) global wasted work (GWW) may provide complementary insight into maladaptive RV remodeling.<br/><br/>Objectives<br/>To contextualize the prognostic value of RV GWW relative to TAPSE/sPAP and clarify their mechanistic and clinical complementarity.<br/><br/>Methods and Results<br/>Patients with elevated GWW (≥38 mmHg/%) exhibited evidence of RV–PA uncoupling, including a reduced RV end-systolic elastance to arterial elastance (Ees/Ea) ratio (0.47 [0.34–0.73] vs. 0.71 [0.50–0.91]; p = 0.007) and lower TAPSE/sPAP ratio (0.21 [0.18–0.32] vs. 0.34 [0.22– 0.45] mm/Hg; p = 0.003) compared with lower GWW. In secondary analyses, a TAPSE/sPAP ratio below the median was associated with increased risk of death or lung transplantation (hazard ratio [HR] 3.20; 95% CI: 1.45–7.08), remaining significant after adjustment for age and sex (adjusted HR 2.97; 95% CI: 1.27–6.94). Discrimination was modest and comparable for TAPSE/sPAP (C-statistic 0.63; 95% CI: 0.53–0.73) and GWW (C-statistic 0.61), with no significant difference between metrics (ΔC = −0.02; p = 0.68).<br/><br/>Conclusions<br/>TAPSE/sPAP remains a robust and clinically valuable surrogate of macroscopic RV–PA coupling. However, GWW offers complementary information by quantifying myocardial inefficiency related to paradoxical and postsystolic deformation, capturing energetic consequences of afterload mismatch that may not be reflected by displacement-based indices alone. Integrating energetic and mechanical markers may enable a more granular assessment of RV performance, particularly in intermediate-risk PH, and warrants evaluation in larger multicenter studies.}},
  author       = {{Venkateshvaran, Ashwin and Lindow, Thomas and Jumatate, Raluca and Kovacs, Attila L. and Ingvarsson, Annika and Lindqvist, Per and Werther Evaldsson, Anna}},
  issn         = {{0742-2822}},
  language     = {{eng}},
  month        = {{01}},
  number       = {{1}},
  pages        = {{1--2}},
  publisher    = {{John Wiley & Sons Inc.}},
  series       = {{Echocardiography}},
  title        = {{Linking Energetic Inefficiency to Ventriculoarterial Uncoupling in Pulmonary Hypertension}},
  url          = {{http://dx.doi.org/10.1111/echo.70389}},
  doi          = {{10.1111/echo.70389}},
  volume       = {{43}},
  year         = {{2026}},
}