Right Ventricular–Pulmonary Artery Coupling in Heart Failure: Assessment and Clinical Significance

Abstract

Background: Right ventricular-pulmonary artery (RV-PA) coupling describes the relationship between right ventricular contractility and the afterload imposed by the pulmonary circulation. It has emerged as an integrated marker of cardiovascular performance and may provide greater diagnostic and prognostic information than conventional measurements of right ventricular function alone. In heart failure, progressive elevation of pulmonary pressures initially triggers compensatory right ventricular hypertrophy; however, persistent afterload leads to maladaptive remodeling, chamber dilation, systolic dysfunction, and eventual RV-PA uncoupling.

Objective: This review summarizes the physiological basis, invasive and non-invasive methods of assessment, clinical significance, prognostic value, and therapeutic implications of RV-PA coupling across heart failure phenotypes.

Review content: Pressure-volume loop analysis remains the invasive reference standard, using the ratio of end-systolic elastance to effective arterial elastance. Because catheter-based assessment is complex and invasive, cardiac magnetic resonance and echocardiographic surrogates are increasingly used in clinical practice. Among these, the ratio of tricuspid annular plane systolic excursion to pulmonary arterial systolic pressure (TAPSE/PASP) is the most extensively validated, while right ventricular free-wall strain-to-PASP is an emerging alternative. Impaired coupling is associated with pulmonary hypertension, elevated natriuretic peptide levels, renal dysfunction, reduced exercise capacity, hospitalization, and cardiovascular mortality. Serial assessment may also identify changes in ventricular-pulmonary vascular interaction after pharmacological or device-based treatment.

Conclusion: RV-PA coupling is a clinically valuable, dynamic measure that integrates right ventricular function and pulmonary vascular load. Its early assessment, particularly using validated non-invasive indices, can improve risk stratification, support treatment selection, and provide an objective measure of therapeutic response in patients with heart failure.