What is the management approach for a patient with an abnormal Tricuspid Annular Plane Systolic Excursion (TAPSE) measurement indicating right ventricular dysfunction?

Management of Abnormal TAPSE

An abnormal TAPSE (<17 mm) requires immediate comprehensive right ventricular assessment with additional echocardiographic parameters, identification of the underlying etiology, and treatment directed at the primary cause while monitoring for clinical decompensation. 1

Defining Abnormal TAPSE Values

• TAPSE <17 mm indicates right ventricular systolic dysfunction and mandates further evaluation 1
• Normal TAPSE is 24 ± 3.5 mm, with values below this suggesting impaired RV longitudinal function 1
• TAPSE <16 mm specifically indicates significant RV pressure overload and serves as a critical cutoff in acute conditions like pulmonary embolism 1
• In acute pulmonary embolism requiring embolectomy, TAPSE <18 mm is an independent predictor of intraoperative cardiopulmonary resuscitation and death 2

Complete Right Ventricular Assessment Required

TAPSE alone is insufficient for management decisions and must be integrated with multiple parameters 1:

• RV fractional area change (RVFAC): Normal >32%; <35% indicates dysfunction 1
• RV dimensions: Mid-RV dimension >33 mm, RV end-diastolic area >28 cm², or RV end-systolic area >16 cm² suggest RV dilation 1
• Tissue Doppler S' velocity: <9.5 cm/s at the tricuspid lateral annulus indicates RV dysfunction 1
• RV free wall strain: Values >-20% (less negative) suggest dysfunction 1

Important Caveat

• In severe tricuspid regurgitation, TAPSE may be less accurate and should be interpreted cautiously 1
• TAPSE correlates more strongly with left ventricular ejection fraction than with RV function indices in critically ill patients, so consider LV function as a confounding factor 3

Identify the Underlying Etiology

For Acute Pulmonary Embolism

• Look for dilated RV with RV/LV ratio >1.0, paradoxical septal motion, McConnell sign, and distended IVC 1
• Combination of TAPSE <16 mm, RV/LV ratio >1.0, and dilated non-collapsing IVC suggests acute RV failure 1

For Pulmonary Hypertension

• Assess RVSP; if >45 mmHg with TAPSE <1.6 cm, right heart catheterization is required 1, 4
• This combination mandates cardiology referral 1, 4

For Heart Failure

• Higher NYHA functional class correlates with lower TAPSE values (NYHA IV: 12.7 mm vs. NYHA II: 18.8 mm) 5
• Non-ischemic cardiomyopathy shows lower TAPSE values compared to ischemic etiology (12.5 mm vs. 16.6 mm) 5
• Left ventricular ejection fraction, deceleration time of early mitral inflow, and RV end-diastolic diameter are independent determinants of reduced TAPSE 5

Treatment Strategy

Treat the primary etiology while monitoring for clinical decompensation 1:

• For pulmonary embolism: Anticoagulation as primary therapy 1
• For pulmonary hypertension: PAH-specific therapy 1
• For severe tricuspid regurgitation: Surgical intervention may be indicated if symptomatic with progressive RV dysfunction 1

Risk Stratification for Specific Procedures

Pre-TIPS Evaluation Context

• If RVSP >45 mmHg or TAPSE <1.6 cm, cardiology referral for right heart catheterization is required before TIPS procedure 4
• TIPS is contraindicated if LVEF <50% or grade III diastolic dysfunction is present 4
• Post-TIPS echocardiographic surveillance at 3 months (or earlier if clinically indicated) is recommended for patients with cardiac dysfunction 4

Monitoring and Follow-Up

• Serial TAPSE measurements are less suitable for monitoring due to reproducibility issues compared to baseline assessment 1
• Post-intervention echocardiographic surveillance at 3 months (or earlier if clinically indicated) is recommended for patients with cardiac dysfunction or valvular disease 1
• Consider RV ejection fraction by cardiac MRI for more accurate serial assessment, as it is the gold standard for RV function 1

Prognostic Implications

• In pediatric dilated cardiomyopathy, moderate or severe RVSD (TAPSE z-score ≤-4) shows significantly lower event-free survival 6
• TAPSE/RVSP ratio <0.43 mm/mm Hg identifies patients at risk for new-onset RV systolic dysfunction and right heart failure, providing opportunity for proactive interventions 7