
==== Front
Egypt Heart J
Egypt Heart J
The Egyptian Heart Journal
1110-2608
2090-911X
Springer Berlin Heidelberg Berlin/Heidelberg

39249570
554
10.1186/s43044-024-00554-7
Research
Role of right ventricular–pulmonary arterial coupling assessed by echocardiography to predict adverse outcomes in patients with acute pulmonary embolism
http://orcid.org/0000-0001-8267-7274
Mostafa Amir dramirmostafaoy@gmail.com

1
Medhat Mahmoud 2
Alhosary Hossam 1
Amin Wassim 1
1 https://ror.org/03q21mh05 grid.7776.1 0000 0004 0639 9286 Cardiovascular Department, Cairo University, Cairo, Egypt
2 https://ror.org/055273664 grid.489068.b 0000 0004 0554 9801 National Heart Institute, Cairo, Egypt
9 9 2024
9 9 2024
12 2024
76 12230 4 2024
30 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Background

Pulmonary embolism (PE) is a lethal type of venous thromboembolic disease. Right ventricular (RV) failure is not an uncommon complication of PE leading to higher adverse outcomes. The tricuspid annular peak systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio as a surrogate for RV–pulmonary artery coupling has proven to be among the predictor of clinical outcomes in multiple patient groups. We evaluated in this study the role of TAPSE/PASP ratio in predicting adverse clinical outcomes in patients with acute PE.

Results

Among patients with established diagnosis of acute PE admitted to the coronary care unit, echocardiography was done within 12 h of admission and TAPSE/PASP ratio was calculated. The patients were followed during hospitalization and after discharge for 3 months for development of adverse outcomes including rehospitalization due to heart failure, recurrent PE and mortality. A total of fifty-five consecutive patients were recruited with mean age 58.3 ± 6.9 years and nearly equal male-to-female ratio. The mean ratio of TAPSE/PASP was 0.479 ± 0.206. In-hospital and 3-month follow-up showed that 10.9% needed rehospitalization with heart failure, 14.5% developed recurrent pulmonary embolism, and mortality was 9.1%. TAPSE/PASP ratio was significantly lower among the patients who developed adverse outcomes. TAPSE/PASP ratio was among the independent predictors of rehospitalization with heart failure, recurrent pulmonary embolism but not mortality at 3-month follow-up. TAPSE/PASP ratio predicted rehospitalization with heart failure at a cutoff point ≤ 0.325, with 100% sensitivity and 79.6% specificity, and predicted recurrent pulmonary embolism at a cutoff point ≤ 0.325, with 75% sensitivity and 78.7% specificity.

Conclusion

TAPSE/PASP ratio is a noninvasive tool that can predict the development of early adverse outcomes in patients with acute PE including rehospitalization with heart failure and recurrent pulmonary embolism.

Keywords

Pulmonary embolism
RV–PA coupling
Echocardiography
TAPSE/PASP ratio
issue-copyright-statement© Egyptian Society of Cardiology 2024
==== Body
pmcBackground

Pulmonary embolism (PE) is a lethal type of venous thromboembolic disease. It is considered the third among the cause of cardiovascular mortality with in-hospital mortality rates between 5 and 10% [1, 2].

Right ventricular (RV)–pulmonary artery (PA) coupling refers to relation between the RV afterload and the RV contractility. Chronic conditions associated with increased pulmonary artery (PA) pressure and RV afterload provide time for the RV contractility to increase to try to maintain the RV–PA coupling. This is not the case for acute conditions as acute PE, so this leads to failure of this balance causing acute RV failure that is associated with increased adverse clinical outcomes mainly rehospitalization and mortality [3].

RV failure complicates 30% of acute PE patients leading to 5% in-hospital mortality. This emphasizes the importance of early detection of RV dysfunction in these patients [4].

The main method for assessing the RV–PA coupling is the right heart catheterization (RHC). Multiple research has been conducted to find noninvasive modalities to evaluate RV–PA coupling including echocardiographic measurement of the ratio between tricuspid annular peak systolic excursion and pulmonary artery systolic pressure (TAPSE/PASP) [3].

The predictive value of TAPSE/PASP ratio has been evaluated in multiple patient groups including patients with pulmonary hypertension, heart failure, valvular heart disease and post-cardiac surgery [5–9].

Few studies addressed the predictive value of TAPSE/PASP ratio in patients with acute PE. We aimed in this study to evaluate the predictive role of TAPSE/PASP to detect adverse clinical outcomes in acute PE patients.

Methods

The study was cross-sectional analytical prospective including fifty-five patients with confirmed diagnosis of acute PE admitted to the intensive care unit of the cardiovascular department of Kasr Alainy Hospital, Cairo University, in the period between January 2023 and January 2024.

Eligible participants included patients ≥ 18 years admitted with normotensive acute PE according to the latest European Society of Cardiology guidelines [10]. Exclusion criteria included previous PE, history of RV dysfunction, history of tricuspid valve disease or tricuspid valve replacement, PE due to malignancy, PE with hemodynamic instability and technical difficulties in assessing RV–PA coupling by echocardiography.

After obtaining informed consent [11], history and physical examination data were collected. Laboratory workup and 12-lead electrocardiogram were done. Within 12 h of admission, transthoracic echocardiography was done using a vivid machine equipped with a transthoracic 2.5 MHz transducer. Echocardiographic parameters assessed included left ventricular (LV) size, LV contractility, right atrial (RA) size, RV size and PASP. RV systolic function was evaluated by RV S wave velocity, RV fractional area changes (RV-FAC) and TAPSE. TAPSE/PASP ratio was used as a measure for RV–PA coupling.

All patients were followed during their hospital admission for their clinical status and after discharge for 3 months to detect the development of short-term outcomes including rehospitalization with heart failure, recurrent pulmonary embolism and mortality.

Statistical analysis was conducted using Statistical Package for the Social Science (SPSS) 28th edition. Mann–Whitney's and Chi-square tests were used to evaluate nonparametric and parametric variables, respectively. Univariate and multivariate regression analyses were used to detect the predictors of development of adverse outcomes. A receiver operator characterized curve (ROC) was constructed to assess the sensitivity, specificity and area under the curve (AUC) of TAPSE/PASP ratio to predict adverse outcomes and to set optimal cutoff point for development of these adverse outcomes. P value < 0.05 was used to prove statistical significance.

Results

Basic demographic data of patients are illustrated in Table 1; nearly half of patients were males with mean age 58.3 ± 6.9 years. All laboratory workup was within normal except for elevated levels of HbA1C, as illustrated in Table 2.Table 1 Basic demographic and clinical data of the patients enrolled with acute pulmonary embolism

Demographic and clinical parameters	Frequency (%)/Mean ± SD	
Age	58.3 ± 6.9	
Male gender	28 (50.9)	
Body mass index (BMI) (kg/m2)	30.06 ± 2.27	
Heart rate	75 ± 12.6	
Respiratory rate (breath/min)	14.1 ± 1.48	
Mean arterial pressure (mmHg)	105.8 ± 16	
Smoking	24 (43.6)	
Diabetes mellitus	32 (58.2)	
Hypertension	38 (69.1)	
Family history of coronary artery disease	13 (23.6)	

Table 2 Laboratory data of the patients enrolled with acute pulmonary embolism

Laboratory parameters	Mean ± SD	
Hb (g/dL)	13.67 ± 1.5	
Platelets (103/μL)	233.07 ± 51.8	
TLC (103/μL)	8.46 ± 2.8	
Creatinine (mg/dL)	1.004 ± 0.203	
Urea (mg/dL)	36.05 ± 5.9	
Na (mEq/L)	138.58 ± 2.86	
K (mEq/L)	4.187 ± 0.43	
INR	0.995 ± 0.106	
HbA1C (mg/dL)	7.19 ± 1.65	
Hb hemoglobin, TLC total leukocytic count, HbA1C glycosylated hemoglobin, INR International Normalized Ratio

Echocardiographic data revealed normal mean LV dimensions and contractility, normal mean RA dimensions, normal mean RV dimensions and normal RV systolic function. The mean ratio of TAPSE/PASP was 0.479 ± 0.206 (Table 3).Table 3 Echocardiographic profile of the patients enrolled with acute pulmonary embolism

Echocardiographic parameters	Mean ± SD	
LVEDD (mm)	4.84 ± 0.6	
LVESD (mm)	3.2 ± 0.55	
Ejection fraction %	60.44 ± 7.09	
Right atrial size (cm)	3.244 ± 0.34	
Right ventricle 1 size (cm)	3.99 ± 1.1	
Right ventricle 2 size (cm)	3.76 ± 0.84	
Right ventricle 3 size (cm)	6.65 ± 0.86	
Right ventricle-FAC %	39.66 ± 9	
IVC diameter (cm)	1.88 ± 0.26	
DTI S’ (mm/s)	9.32 ± 2.5	
TAPSE (mm)	18.2 ± 4.6	
PASP (mmHg)	41.8 ± 12.4	
TAPSE/PASP ratio	0.479 ± 0.206	
DTI Doppler tissue imaging, FAC fractional area change, LVESD left ventricular end systolic volume, LVESD left ventricular end diastolic volume, IVC inferior vena cava, PASP pulmonary artery systolic pressure, TAPSE tricuspid annular plane systolic excursion

At 3-month follow-up, mortality accrued in 9% of the patients (Table 4).Table 4 Adverse outcomes of the patients enrolled with acute pulmonary embolism

Adverse outcomes	Frequency (%)	
Rehospitalization with heart failure	6 (10.9)	
Recurrent pulmonary embolism	8 (14.5)	
Mortality	5 (9.1)	

Binary logistic regression was executed for factors predicting occurrence of adverse events (Tables 5, 6, 7), where TAPSE/PASP ratio predicted rehospitalization with heart failure, with an odds ratio of 0.964. Also, TAPSE/PASP ratio predicted occurrence of recurrent pulmonary embolism, with an odds ratio of 0.99, while it couldn’t predict mortality.Table 5 Binary logistic regression for factors predicting rehospitalization with heart failure in the patients enrolled with acute pulmonary embolism

Parameters	Sig.	Odds Ratio	95% CI	
Lower	Upper	
Age	0.229	0.854	0.661	1.1	
Sex	0.231	7.78	0.270	22.39	
Diabetes mellitus	0.130	23.3	0.397	136.55	
Mean arterial pressure	0.433	1.05	0.926	1.19	
TAPSE/PASP	0.046	0.964	0.931	0.99	
PASP pulmonary artery systolic pressure, TAPSE tricuspid annular plane systolic excursion

Table 6 Binary logistic regression for factors predicting recurrent pulmonary embolism in the patients enrolled with acute pulmonary embolism

Parameters	Sig.	Odds ratio	95% CI	
Lower	Upper	
Age	0.772	0.975	0.822	1.16	
Sex	0.234	0.247	0.025	2.46	
Diabetes mellitus	0.065	0.087	0.006	1.16	
Mean arterial pressure	0.857	1.006	0.942	1.07	
TAPSE/PASP	0.02	0.99	0.981	0.998	
INR	0.545	0.043	0.0	114.78	
PASP pulmonary artery systolic pressure, TAPSE tricuspid annular plane systolic excursion

Table 7 Binary logistic regression for factors predicting mortality in the patients enrolled with acute pulmonary embolism

Variable	Sig.	Odds ratio	95% CI	
Lower	Upper	
Age	0.996	0.001	0.00	–	
Sex	0.995	1.9	0.00	–	
Diabetes mellitus	0.999	0.00	0.00	–	
Mean arterial pressure	0.996	3.7	0.00	2.9	
TAPSE/PASP ratio	0.989	0.00	0.00	–	
TAPSE tricuspid annular plane systolic excursion, PASP pulmonary artery systolic pressure

ROC curve analysis showed that TAPSE/PASP ratio predicted rehospitalization with heart failure at a cutoff point ≤ 0.325, with 100% sensitivity and 79.6% specificity. It also predicted recurrent pulmonary embolism at a cutoff point ≤ 0.325, with 75% sensitivity and 78.7% specificity (Table 8, Figs. 1, 2).Table 8 ROC analysis for TAPSE/PASP ratio in predicting different outcomes for the patients enrolled with acute pulmonary embolism

Parameters	Cutoff	Sensitivity (%)	Specificity (%)	AUC (95% CI)	P value	
Rehospitalization with heart failure	≤ 0.325	100	79.6	0.912 (0.834–0.989)	0.001	
Recurrent pulmonary embolism	≤ 0.325	75	78.7	0.814 (0.669–0.958)	0.005	

Fig. 1 Area under the curve for rehospitalization with heart failure

Fig. 2 Area under the curve for recurrent pulmonary embolism

Discussion

The main findings of this study include:Among the recruited patients, 10.9% needed rehospitalization with heart failure, 14.5% developed recurrent pulmonary embolism, and mortality was 9.1% through a period of three months follow up.

TAPSE/PASP ratio was significantly lower among patients who developed adverse outcomes.

TAPSE/PASP ratio was among the independent predictors of rehospitalization with heart failure, recurrent pulmonary embolism but not mortality at 3-month follow-up.

TAPSE/PASP ratio predicted rehospitalization with heart failure at a cutoff point ≤ 0.325, with 100% sensitivity and 79.6% specificity, and predicted recurrent pulmonary embolism at a cutoff point ≤ 0.325, with 75% sensitivity and 78.7% specificity.

Multiple studies validated TAPSE/PASP ratio as a simple, noninvasive echocardiographic method for evaluating RV–PA coupling [3]. TAPSE/PASP ratio has been studied as a predictor of clinical adverse outcomes in multiple patient groups. Among patients with heart failure, TAPSE/PASP ratio was among the important prognostic variables for adverse outcomes [5]. Also, TAPSE/PASP ratio predicted the occurrence of adverse outcomes among pulmonary hypertension patients [6]. In the Global-Tri-Valve registry, among patients with tricuspid regurgitation scheduled for percutaneous intervention either repair or replacement, TAPSE/PASP ratio predicted the occurrence of 12-month all-cause mortality [7]. Also, in the EuroSMR registry that included severe mitral incompetence patients indicated for percutaneous valve replacement [8], TAPSE/PASP ratio was an independent predictor of 24-month mortality. Partner 3 trial showed that TAPSE/PASP ratio independently predicted 2-year composite adverse outcomes among low-risk patients with symptomatic severe aortic stenosis indicated for percutaneous or surgical valve replacement [9].

The value of TAPSE/PASP ratio in predicting adverse outcomes in patients with acute PE is not well studied. In this study, TAPSE/PASP ratio independently predicted the occurrence of adverse clinical outcomes in acute PE patients including rehospitalization with heart failure and recurrent pulmonary embolism at 3-month follow-up. This can be explained by the acute desynchrony between the RV afterload and RV contractility that occurs in acute PE patients due to acute increase in RV afterload unmatched by similar compensatory increase in the RV contractility. This desynchrony is reflected on the TAPSE/PASP ratio. This is concordant with the results of a recent study involving patients with acute PE evaluated multiple echocardiographic parameters that can assess RV–PA coupling. This study showed that TAPSE/PASP ratio was independently associated with adverse events during hospitalization [12]. Also, another recent retrospective study involving acute PE patients showed that TAPSE/PASP ratio predicted the development of 7-day adverse outcomes including mortality and hemodynamic compromise. In this study, a cutoff value of 0.4 for the TAPSE/PASP ratio was identified as the optimal cutoff value for predicting adverse clinical outcome in patients with acute PE [13].

Limitations of the study

The limitations of the study include that it is a single-center study. Also, TAPSE provides data about the longitudinal rather than the global RV function. RHC is the gold standard for assessment of the PASP; however, in this study we used the echocardiographic assessment.

Conclusions

TAPSE/PASP ratio is a noninvasive tool that can predict development of early adverse clinical outcomes among patients with acute PE including rehospitalization with heart failure and recurrent pulmonary embolism. Further multicenter studies are needed to validate the use of this bedside parameter to predict adverse outcomes in this critical patient group.

Abbreviations

PE Pulmonary embolism

RV Right ventricle

PA Pulmonary artery

TAPSE Tricuspid annular peak systolic excursion

PASP Pulmonary artery systolic pressure

LV Left ventricle

EF Ejection fraction

RA Right atrium

FAC Fractional area change

ROC Receiver operator characterized

Acknowledgements

Not applicable.

Author contributions

AM, MM, HH and WA shared in the study idea, collection and analysis of data and finalizing the results. All authors read and approved the final manuscript.

Funding

None.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval

Ethical approval was obtained by the ethical committee of Cairo University, Faculty of Medicine in 28/2/2023, and the reference number is (MS-232-2023).

Consent to participate

Informed written consent to participate in the study was obtained from all recruited patients.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Turetz M Sideris AT Friedman OA Triphathi N Horowitz JM Epidemiology, pathophysiology, and natural history of pulmonary embolism Semin Intervent Radiol 2018 35 2 92 98 10.1055/s-0038-1642036 29872243
Turetz M, Sideris AT, Friedman OA, Triphathi N, Horowitz JM (2018) Epidemiology, pathophysiology, and natural history of pulmonary embolism. Semin Intervent Radiol 35(2):92–9829872243 10.1055/s-0038-1642036
2. Arrigo M Huber LC Winnik S Mikulicic F Guidetti F Frank M Ruschitzka F Right ventricular failure: pathophysiology, diagnosis and treatment Card Fail Rev 2019 5 3 140 10.15420/cfr.2019.15.2 31768270
Arrigo M, Huber LC, Winnik S, Mikulicic F, Guidetti F, Frank M, Ruschitzka F (2019) Right ventricular failure: pathophysiology, diagnosis and treatment. Card Fail Rev 5(3):14031768270 10.15420/cfr.2019.15.2
3. He Q Lin Y Zhu Y Gao L Ji M Zhang L Xie M Li Y Clinical usefulness of right ventricle-pulmonary artery coupling in cardiovascular disease J Clin Med 2023 12 7 2526 10.3390/jcm12072526 37048609
He Q, Lin Y, Zhu Y, Gao L, Ji M, Zhang L, Xie M, Li Y (2023) Clinical usefulness of right ventricle-pulmonary artery coupling in cardiovascular disease. J Clin Med 12(7):252637048609 10.3390/jcm12072526
4. Grifoni S Olivotto I Cecchini P Pieralli F Camaiti A Santoro G Conti A Agnelli G Berni G Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction Circulation 2000 101 2817 2822 10.1161/01.CIR.101.24.2817 10859287
Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, Conti A, Agnelli G, Berni G (2000) Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 101:2817–282210859287 10.1161/01.CIR.101.24.2817
5. Bosch L Lam CSP Gong L Chan SP Sim D Yeo D Jaufeerally F Leong KTG Ong HY Ng TP Richards AM Arslan F Ling LH Right ventricular dysfunction in left-sided heart failure with preserved versus reduced ejection fraction Eur J Heart Fail 2017 19 12 1664 1671 10.1002/ejhf.873 28597497
Bosch L, Lam CSP, Gong L, Chan SP, Sim D, Yeo D, Jaufeerally F, Leong KTG, Ong HY, Ng TP, Richards AM, Arslan F, Ling LH (2017) Right ventricular dysfunction in left-sided heart failure with preserved versus reduced ejection fraction. Eur J Heart Fail 19(12):1664–167128597497 10.1002/ejhf.873
6. Li Y Guo D Gong J Wang J Huang Q Yang S Zhang X Hu H Jiang Z Yang Y Lu X Right ventricular function and its coupling with pulmonary circulation in precapillary pulmonary hypertension: a three-dimensional echocardiographic study Front Cardiovasc Med 2021 8 690606 10.3389/fcvm.2021.690606 34277739
Li Y, Guo D, Gong J, Wang J, Huang Q, Yang S, Zhang X, Hu H, Jiang Z, Yang Y, Lu X (2021) Right ventricular function and its coupling with pulmonary circulation in precapillary pulmonary hypertension: a three-dimensional echocardiographic study. Front Cardiovasc Med 8:69060634277739 10.3389/fcvm.2021.690606
7. Brener MI Lurz P Hausleiter J Rodés-Cabau J Fam N Kodali SK Rommel KP Muntané-Carol G Gavazzoni M Nazif TM Pozzoli A Alessandrini H Latib A Biasco L Braun D Brochet E Denti P Lubos E Ludwig S Kalbacher D Estevez-Loureiro R Connelly KA Frerker C Ho EC Juliard JM Harr C Monivas V Nickenig G Pedrazzini G Philippon F Praz F Puri R Schofer J Sievert H Tang GHL Andreas M Thiele H Unterhuber M Himbert D Alcázar MU Von Bardeleben RS Windecker S Wild MG Maisano F Leon MB Taramasso M Hahn RT Right ventricular- pulmonary arterial coupling and afterload reserve in patients undergoing transcatheter tricuspid valve repair J Am Coll Cardiol 2022 79 5 448 461 10.1016/j.jacc.2021.11.031 35115101
Brener MI, Lurz P, Hausleiter J, Rodés-Cabau J, Fam N, Kodali SK, Rommel KP, Muntané-Carol G, Gavazzoni M, Nazif TM, Pozzoli A, Alessandrini H, Latib A, Biasco L, Braun D, Brochet E, Denti P, Lubos E, Ludwig S, Kalbacher D, Estevez-Loureiro R, Connelly KA, Frerker C, Ho EC, Juliard JM, Harr C, Monivas V, Nickenig G, Pedrazzini G, Philippon F, Praz F, Puri R, Schofer J, Sievert H, Tang GHL, Andreas M, Thiele H, Unterhuber M, Himbert D, Alcázar MU, Von Bardeleben RS, Windecker S, Wild MG, Maisano F, Leon MB, Taramasso M, Hahn RT (2022) Right ventricular- pulmonary arterial coupling and afterload reserve in patients undergoing transcatheter tricuspid valve repair. J Am Coll Cardiol 79(5):448–46135115101 10.1016/j.jacc.2021.11.031
8. Karam N Stolz L Orban M Deseive S Praz F Kalbacher D Westermann D Braun D Näbauer M Neuss M Butter C Kassar M Petrescu A Pfister R Iliadis C Unterhuber M Park SD Thiele H Baldus S Stephan von Bardeleben R Blankenberg S Massberg S Windecker S Lurz P Hausleiter J Impact of right ventricular dysfunction on outcomes after transcatheter edge-to-edge repair for secondary mitral regurgitation JACC Cardiovasc Imaging 2021 14 4 768 778 10.1016/j.jcmg.2020.12.015 33582067
Karam N, Stolz L, Orban M, Deseive S, Praz F, Kalbacher D, Westermann D, Braun D, Näbauer M, Neuss M, Butter C, Kassar M, Petrescu A, Pfister R, Iliadis C, Unterhuber M, Park SD, Thiele H, Baldus S, Stephan von Bardeleben R, Blankenberg S, Massberg S, Windecker S, Lurz P, Hausleiter J (2021) Impact of right ventricular dysfunction on outcomes after transcatheter edge-to-edge repair for secondary mitral regurgitation. JACC Cardiovasc Imaging 14(4):768–77833582067 10.1016/j.jcmg.2020.12.015
9. Cahill TJ Pibarot P Yu X Babaliaros V Blanke P Clavel MA Douglas PS Khalique OK Leipsic J Makkar R Alu MC Kodali S Mack MJ Leon MB Hahn RT Impact of right ventricle-pulmonary artery coupling on clinical outcomes in the PARTNER 3 trial JACC Cardiovasc Interv 2022 15 18 1823 1833 10.1016/j.jcin.2022.07.005 36137685
Cahill TJ, Pibarot P, Yu X, Babaliaros V, Blanke P, Clavel MA, Douglas PS, Khalique OK, Leipsic J, Makkar R, Alu MC, Kodali S, Mack MJ, Leon MB, Hahn RT (2022) Impact of right ventricle-pulmonary artery coupling on clinical outcomes in the PARTNER 3 trial. JACC Cardiovasc Interv 15(18):1823–183336137685 10.1016/j.jcin.2022.07.005
10. Konstantinides SV Meyer G Becattini C Bueno H Geersing G-J Harjola V-P Huisman MV Humbert M Jennings CS Jiménez D Kucher N Lang IM Lankeit M Lorusso R Mazzolai L Meneveau N Ní Áinle F Prandoni P Pruszczyk P Righini M Torbicki A Van Belle E Zamorano JL ESC Scientific Document Group 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC) Eur Heart J 2020 41 4 543 603 10.1093/eurheartj/ehz405 31504429
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing G-J, Harjola V-P, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL, ESC Scientific Document Group (2020) 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Heart J 41(4):543–60331504429 10.1093/eurheartj/ehz405
11. Goodyear MD Eckenwiler LA Ells C Fresh thinking about the Declaration of Helsinki BMJ 2008 337 a2128 10.1136/bmj.a2128 18930967
Goodyear MD, Eckenwiler LA, Ells C (2008) Fresh thinking about the Declaration of Helsinki. BMJ 337:a212818930967 10.1136/bmj.a2128
12. Kiamanesh O Prosperi-Porta G Harper L Solverson K Boiteau P Helmersen D Ferland A Fine N Weatherald J Ventricular-arterial decoupling is associated with in-hospital adverse events in normotensive pulmonary embolism Int J Cardiovasc Imaging 2022 38 12 2655 2665 10.1007/s10554-022-02677-x 36445659
Kiamanesh O, Prosperi-Porta G, Harper L, Solverson K, Boiteau P, Helmersen D, Ferland A, Fine N, Weatherald J (2022) Ventricular-arterial decoupling is associated with in-hospital adverse events in normotensive pulmonary embolism. Int J Cardiovasc Imaging 38(12):2655–2665. 10.1007/s10554-022-02677-x. (Epub 2022 Jul 15)36445659 10.1007/s10554-022-02677-x
13. Lyhne MD Kabrhel C Giordano N Andersen A Nielsen-Kudsk JE Zheng H Dudzinski DM The echocardiographic ratio tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure predicts short-term adverse outcomes in acute pulmonary embolism Eur Heart J Cardiovasc Imaging 2021 22 3 285 294 10.1093/ehjci/jeaa243 33026070
Lyhne MD, Kabrhel C, Giordano N, Andersen A, Nielsen-Kudsk JE, Zheng H, Dudzinski DM (2021) The echocardiographic ratio tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure predicts short-term adverse outcomes in acute pulmonary embolism. Eur Heart J Cardiovasc Imaging 22(3):285–29433026070 10.1093/ehjci/jeaa243
