Solving the Pulmonary Hypertension Paradox in Patients With Severe Tricuspid Regurgitation by Employing Artificial Intelligence

OBJECTIVES This study aimed to improve echocardiographic assessment of pulmonary hypertension (PH) in patients presenting with severe tricuspid regurgitation (TR). BACKGROUND Echocardiographic assessment of PH in patients with severe TR carries several pitfalls for underestimation, hence concealing the true severity of PH in very sick patients in particular, and ultimately obscuring the impact of PH on survival after transcatheter tricuspid valve intervention (TTVI). METHODS All patients in this study underwent TTVI for severe TR between 2016 and 2020. To predict the mean pulmonary artery pressure (mPAP) solely based on echocardiographic parameters, we trained an extreme gradient boosting (XGB) algorithm. The derivation cohort was constituted by 116 out of 162 patients with both echocardiography and right heart catheterization data, preprocedurally obtained, from a bicentric registry. Moreover, 142 patients from an independent institution served for external validation. RESULTS Systolic pulmonary artery pressure was consistently underestimated by echocardiography in comparison to right heart catheterization (40.3 +/- 15.9 mm Hg vs 44.1 +/- 12.9 mm Hg; P = 0.0066), and the assessment was most discrepant among patients with severe defects of the tricuspid valve and impaired right ventricular systolic function. Using 9 echocardiographic parameters as input variables, an XGB algorithm could reliably predict mPAP levels (R = 0.96, P < 2.2 x 10(-16)). Moreover, patients with elevations in predicted mPAP levels >= 29.9 mm Hg showed significantly reduced 2-year survival after TTVI (58.3% [95% CI: 41.7%-81.6%] vs 78.8% [95% CI: 68.7%-90.5%]; P = 0.026). Importantly, the poor prognosis associated with elevation in predicted mPAP levels was externally confirmed (HR for 2-year mortality: 2.9 [95% CI: 1.5-5.7]; P = 0.002). CONCLUSIONS PH in patients with severe TR can be reliably assessed based on echocardiographic parameters in conjunction with an XGB algorithm, and elevations in predicted mPAP levels translate into increased mortality after TTVI. (C) 2022 by the American College of Cardiology Foundation.

Automated summary

This study aimed to improve the assessment of pulmonary hypertension (PH) in patients with severe tricuspid regurgitation (TR) using echocardiography. An extreme gradient boosting (XGB) algorithm was trained to predict mean pulmonary artery pressure (mPAP) based on echocardiographic parameters. The results showed that echocardiography consistently underestimated systolic pulmonary artery pressure compared to right heart catheterization. The XGB algorithm using 9 echocardiographic parameters could reliably predict mPAP levels. Patients with elevated predicted mPAP levels showed significantly reduced 2-year survival after transcatheter tricuspid valve intervention (TTVI). This study highlights the importance of accurate assessment of PH in patients with severe TR.