Abstract 10685: Right Ventricular-Pulmonary Arterial Coupling in Heart Failure Patients with Secondary Mitral Regurgitation: Analysis from the COAPT Trial

Objectives: We sought to determine the prognostic impact of right ventricular (RV) function characterized by RV-pulmonary arterial (PA) coupling in heart failure (HF) patients with severe secondary mitral regurgitation (SMR) enrolled in the COAPT trial. Background: RV contractile function and PA pressures influence outcomes in patients with SMR, but the impact of RV-PA coupling in patients randomized to transcatheter edge-to-edge repair (TEER) versus guideline-directed medical therapy (GDMT) has not been examined. Methods: We assessed RV-PA coupling by the ratio of RV free wall longitudinal strain (FWLS) derived from speckle-tracking echocardiography (STE) and non-invasively measured RV systolic pressure (RVSP). Advanced RV-PA uncoupling was defined by RVFWLS/RVSP ≤0.5. The primary endpoint was a composite of all-cause mortality or HF hospitalization at 24-month follow-up. Results: A total of 372 patients underwent STE, among whom 70.2% had advanced RV-PA uncoupling. By multivariable analysis, advanced RV-PA uncoupling was strongly associated with an increased risk for the primary 24-month endpoint of death or HF hospitalization (HR 1.87, 95% CI 1.31-2.66, p=0.0005). A similar association was present for all-cause mortality alone (HR 2.57, 95% CI 1.54-4.29, p=0.0003). The impact of RV-PA uncoupling was consistent in patients randomized to TEER and GDMT alone. TEER improved 2-year outcomes both in patients with (48.0% vs. 74.8%, HR 0.51, 95% CI 0.37-0.71) and without (28.8% vs. 47.8%, HR 0.51, 95% CI 0.27-0.97) advanced RV-PA uncoupling (pinteraction=0.98). Conclusions: In the COAPT trial, advanced RV-PA uncoupling was a powerful predictor of 2-year adverse outcomes ( Figure 1 ), reinforcing the importance of RV dysfunction in patients with HF.