Abstract
Background
Tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) as a noninvasively measured index of right ventricular-pulmonary artery uncoupling is associated with poor outcomes in heart failure patients. However, the relationship by which the TAPSE/PASP is linked to atrial fibrillation (AF) in peritoneal dialysis (PD) patients is not clear. We aimed to investigate the relationship between the TAPSE/PASP and AF in PD patients.
Methods
This study was divided into two parts. First, we included 329 PD patients. All the subjects provided detailed a medical history, laboratory analysis and transthoracic echocardiography on admission. We evaluated the differences in the TASPE/PASP ratios between the AF and non-AF groups. Second, a total of 121 patients were followed up to compare mortality between the AF and non-AF groups.
Results
Age, BNP, RDW, LA, and septal E/e’ were significantly higher, and TAPSE/PASP was significantly lower in patients with AF than in those without AF (p < 0.05). Moreover, the TAPSE/PASP was more pronounced in persistent AF patients. PD patients with AF had a greater risk of mortality (7.2%) than did those without AF (3.8%) after an average follow-up of 12 months. Kaplan–Meier analysis revealed that patients with TAPSE/PASP ratios ≤ 0.715 had a greater risk of mortality than did those with TAPSE/PASP ratios > 0.715.
Conclusions
The results suggested that the TAPSE/PASP was lower in AF patients than in non-AF patients. The TAPSE/PASP may be a useful factor for predicting mortality in AF patients with PD, but large-scale prospective studies are needed for verification.
Keywords: Atrial fibrillation, right ventricular function, tricuspid annular plane systolic excursion, pulmonary artery systolic pressure, peritoneal dialysis
Introduction
Chronic kidney disease (CKD) is associated with a disproportionately high mortality and economic burden. The global prevalence of CKD of stages 1 to 5 is 13.4%, and that of stages 3 to 5 is 10.6% [1]. Approximately 11% of dialysis is performed via peritoneal dialysis (PD), an alternative method to intermittent hemodialysis (IHD) in the treatment of renal failure [2]. Currently, an increasing number of young patients on dialysis are choosing PD because of its convenience. However, given the younger age of the PD population, the cardiovascular complications and mortality of PD patients have not received much attention. Along with those with end-stage renal disease (ESRD), patients undergoing dialysis might have concomitant diseases such as nonvalvular atrial fibrillation (AF) and heart failure (HF). AF is the most common type of arrhythmia and is an important cause of cardiovascular morbidity [3]. AF and CKD frequently coexist, amplifying the risk of cardiovascular events and mortality. Therefore, it is necessary to find a more promising and inexpensive method to early identify high-risk of AF in the PD population.
AF and HF are age-related diseases that are increasing in incidence, commonly coexist, and share common clinical features [4,5]. HF syndrome arises as a consequence of an abnormality in cardiac structure, function, rhythm, or conduction, including impaired right ventricular dysfunction, pulmonary hypertension (PH) and a high burden of AF. Left heart disease is the main cause of PH, accounting for 65–80% of cases [6]. PH is associated with the occurrence of AF [7]. The question of whether the AF is driving or significantly contributing to left ventricular (LV) dysfunction, rather than merely a consequence of HF, has become ever more pertinent. Permanent AF patients exhibit severe atrial dysfunction and abnormal right ventricular-pulmonary vascular (RV-PA) coupling [8,9]. As the burden of AF increases, left atrium (LA) compliance and mechanics in HF patients gradually decline, and these changes promote the progression of right heart failure and the worsening of pulmonary vascular diseases. In patients with ESKD receiving PD therapy, the prevalence of PH is estimated to be between 12.6% and 33.3% [10]. In the current classification, PH induced by CKD is categorized into Group 5 due to its unclear and/or multifactorial mechanisms [11]. Multiple mechanisms are involved in this type of PH, such as chronic blood volume expansion, severe anemia, fluid overload, left heart failure and calcification of the pulmonary artery due to secondary hyperparathyroidism [10,11]. A novel noninvasive echocardiographic parameter, the RV–PA coupling parameter, has emerged as an integrative measure of RV performance under varying afterload conditions [9]. This parameter, which is measured as the ratio of the tricuspid annular plane systolic excursion to the pulmonary artery systolic pressure ratio (TAPSE/PASP), is an invaluable noninvasive marker that encapsulates the interplay between RV contractile function and pulmonary hemodynamics and has crucial prognostic implications. Recently, a large body of evidence has revealed the prognostic role of echocardiographically assessed RV–PA coupling in chronic [12] and acute HF patients [13], as well as in recipients of interventional HF treatments, including cardiac resynchronization therapy (CRT) [14] and transcatheter repair of functional mitral regurgitation (MR) or tricuspid regurgitation [15,16]. Recently, the TAPSE/PASP was proven to be a predictive factor of late recurrence of AF/atrial tachycardia independent of left atrial function after catheter ablation in persistent AF patients [17]. However, no studies have investigated the relationship between the TAPSE/PASP and the occurrence of AF in PD patients. Therefore, we sought to investigate the relationships between the TAPSE/PASP and the risk of AF, as well as mortality, in PD patients.
Methods
Patient enrollment
This study was divided into two parts. First, a total of 329 consecutive maintenance PD patients who were admitted to our department of nephrology in the retrospective cross-sectional (snapshot) study between October 2021 and October 2023 were enrolled to the study. All the patients enrolled were aged >18 years and had a dialysis vintage >3 months. Dialysis modalities was continuous ambulatory peritoneal dialysis (CAPD). The definition of the AF is widely known clinical guideline [18]. AF was defined as the absence of P waves and an irregular R-R interval on a 12-lead electrocardiogram (ECG) or 24-h Holter recording. Paroxysmal AF was diagnosed if the episodes of atrial fibrillation were self-terminating and occurred for no longer than 7 days. Persistent AF was defined as AF persisting for more than 1 week. Patients with acute and chronic heart failure, congenital heart diseases, cardiomyopathy, malignancy, autoimmune diseases, or inflammatory diseases were excluded from the study. Second, cases collected between January 2023 and October 2023 were followed up until April 2024 in the perspective study to compare mortality in the AF and non-AF groups. This study was approved by the Ethics Committee of the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine (TYLL2023[Z]013).
Study protocol
In this study, all the subjects provided a detailed medical history and underwent physical examination, 12-lead ECG, laboratory analysis and transthoracic echocardiography (TTE) on admission. Each subject had at least one ECG compatible with AF.
A TTE examination was performed in all patients via the LOGIQ E9 system equipped with a new Agile ultrasonic platform (GE Medical Systems, Milwaukee, WI, USA). Left atrial diameter (LAD), interventricular septal thickness (IVST), left ventricular posterior wall thickness (LVPWT) and left ventricular end-diastolic diameter (LVEDD) were assessed. The left ventricular ejection fraction (LVEF) was determined from apical four-chamber and two-chamber views via Simpson’s biplane formula. The TAPSE was measured in M-mode with a cursor positioned at the tricuspid annulus of the RV-free wall in the left apical 4-chamber view. The M-mode sampling line was parallel to the direction of the tricuspid annulus movement. PASP was determined from the peak velocity of the tricuspid regurgitation (TR) jet via the simplified Bernoulli equation plus the right atrial pressure. Right atrial pressure was estimated on the basis of the diameter and variability with respiration of the inferior vena cava [19]. The exclusion criteria were patients without noticeable TR signals, who lacked either the inspiratory/expiratory phases of inferior vena cava diameters or good image quality. Three consecutive heart cycles were recorded and averaged for patients in sinus rhythm, whereas five heart cycles were averaged for those in AF. All echocardiographic data were analyzed by the same investigator, who was blinded to the clinical status of the participants.
The cases collected between January 2023 and October 2023 were followed up until April 2024, and the follow-up time ranged from 6 months to 15 months. The mortality of patients with PD was recorded. The following factors were investigated in this study: (1) compare the differences between the AF group and the non-AF group; (2) compare the differences between the paroxysmal AF group and persistent AF group; (3) the relationships between mortality and the TAPSE/PASP in PD patients were evaluated.
Statistical analysis
The Kolmogorov–Smirnov test was used to test normality, and a P value >0.05 was used to define normally distributed data. Categorical variables are reported as counts (percentages), and continuous variables are reported as means ± SDs or medians (interquartile ranges). Statistical analysis of data with a normal distribution was performed via Student’s t test, whereas the Mann–Whitney U test was used for nonnormally distributed data, and the chi-square test was used to compare categorical variables. Multiple logistic regression analysis was performed to identify predictors of AF in PD patients. Cox regression analysis was performed to identify predictors of mortality in PD patients. ROC curve analysis was performed to determine the cutoff value of the TAPSE/PASP for the prediction of mortality in PD patients. Kaplan–Meier curves were used for mortality, and statistical significance was determined via the log-rank test. Only P values <0.05 were regarded as statistically significant. All tests were two-tailed, and analyses were performed via the SPSS 22.0 for Windows statistical software (SPSS Inc., IBM Corp).
Results
Clinical and echocardiographic characteristics
The study flowchart is shown in Figure 1. Patients without noticeable TR signals or lacking either the inspiratory or expiratory phases of the inferior vena cava diameters on TTE were excluded. This study population included a total of 329 patients from our Department of Nephrology. The clinical characteristics of the enrolled patients are shown in Tables 1 and 2. Age, BNP, RDW, LA, and septal E/e’ were significantly greater, and TAPSE/PASP was significantly lower, in patients with AF than in those without AF (p < 0.05). Albumin was not different between the AF group and the non-AF group (32.97 ± 4.90 vs. 33.55 ± 4.90, p = 0.291). Single pool-Kt/V was not different between the AF group and the non-AF group, as shown in Table 1, suggesting that there was no difference in blood volume between the two groups. Moreover, TAPSE/PASP was not related to Kt/V (p = 0.453). There was no significant difference in drug use. The TAPSE/PASP was lower in persistent AF patients than in paroxysmal AF patients, as shown in Table 3 (p < 0.001).
Figure 1.
Flow chart of the study patients.
Table 1.
Baseline patient characteristics.
| Overall population (n = 329) |
Non-AF (n = 190) |
AF (n = 139) |
P | |
|---|---|---|---|---|
| Clinical data | ||||
| Age, years | 56.81 ± 11.93 | 54.92 ± 12.28 | 59.39 ± 10.97 | 0.001 |
| Sex, female (n, %) | 148 (45.0) | 82 (43.2) | 66 (47.5) | 0.501 |
| BMI (kg/m2) | 25.20 ± 4.50 | 24.85 ± 4.52 | 25.67 ± 4.42 | 0.098 |
| CHD (n, %) | 117 (35.6) | 63 (33.2) | 54 (38.8) | 0.296 |
| Diabetes mellitus (n, %) | 157 (47.7) | 84 (44.4) | 73 (52.5) | 0.179 |
| Hypertension (n, %) | 312 (94.8) | 183 (96.3) | 129 (92.8) | 0.207 |
| Stroke (n, %) | 88 (26.7) | 38 (20.0) | 35 (25.2) | 0.284 |
| Dyslipidemia (n, %) | 183 (55.6) | 98 (51.6) | 85 (61.2) | 0.093 |
| Smoking habit (n, %) | 113 (34.3) | 62 (32.6) | 51 (36.7) | 0.481 |
| Drinking habit (n, %) | 63 (19.1) | 37 (19.5) | 26 (18.7) | 0.888 |
| Single pool-Kt/V | 1.80 ± 0.30 | 1.80 ± 0.30 | 1.81 ± 0.30 | 0.795 |
| Time of dialysis (mon) | 27 (10-50) | 24 (8.5-45.3) | 34 (11-60) | 0.006 |
| Previous medications (n, %) | ||||
| Aspirin | 193 (58.7) | 103 (54.2) | 90 (64.9) | 0.070 |
| Beta-blocker | 183 (55.6) | 98 (51.6) | 85 (61.2) | 0.093 |
| Calcium channel blocker | 220 (66.9) | 131 (68.9) | 89 (64.0) | 0.407 |
| ACEI/ARB | 210 (63.8) | 117 (61.6) | 93 (66.9) | 0.354 |
| Statin | 204 (62.0) | 113 (59.5) | 91 (65.5) | 0.301 |
| Calcium | 144 (43.8) | 87 (45.8) | 57 (41.0) | 0.431 |
| Dephosphorization agent | 254 (77.2) | 145 (76.3) | 109 (78.4) | 0.691 |
| Iron | 107 (32.5) | 61 (32.1) | 46 (33.1) | 0.905 |
| Erythropoietin | 224 (68.1) | 124 (65.3) | 100 (71.9) | 0.231 |
| Amiodarone | 206 (62.6) | 127 (66.8) | 79 (56.8) | 0.066 |
| Diuretic | 200 (60.8) | 117 (61.6) | 83 (59.7) | 0.733 |
BMI, body mass index; AF, atrial fibrillation; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocking agents; CHD, coronary atherosclerotic heart disease.
Table 3.
Laboratory and echocardiographic parameters of AF population.
| Overall population (n = 139) | Paroxysmal AF (n = 76) | Persistent AF (n = 63) | P | |
|---|---|---|---|---|
| Age, years | 59.39 ± 10.97 | 59.21 ± 11.28 | 59.60 ± 10.68 | 0.834 |
| Stroke (n, %) | 35 (25.2) | 18 (23.7) | 17 (27.0) | 0.698 |
| Aspirin | 90 (64.9) | 47 (61.8) | 43 (68.3) | 0.478 |
| Beta-blocker | 85 (61.2) | 50 (65.8) | 35 (55.6) | 0.227 |
| RDW (%) | 15.44 ± 2.03 | 15.19 ± 1.97 | 15.75 ± 2.07 | 0.105 |
| BNP (pg/mL) | 400.1 (211.6-774.2) | 378.6 (181.7-810.3) | 429.1 (248.6-702.4) | 0.718 |
| LAD (mm) | 39.45 ± 6.77 | 39.88 ± 7.55 | 38.94 ± 5.72 | 0.415 |
| Septal E/e’ | 16.90 ± 5.74 | 16.84 ± 4.29 | 16.99 ± 7.16 | 0.870 |
| TAPSE/PASP (mm/mmHg) | 0.73 ± 0.07 | 0.77 ± 0.06 | 0.68 ± 0.06 | <0.001 |
RDW, Red blood cell distribution width; BNP, brain natriuretic peptide; LAD, left atrial diameter; TAPSE, tricuspid annular plane systolic excursion; PASP, pulmonary artery systolic pressure.
Table 2.
Laboratory and echocardiographic parameters of study population.
| Overall population (n = 329) |
Non-AF (n = 190) |
AF (n = 139) |
P | |
|---|---|---|---|---|
| Laborator parameters | ||||
| White blood cell Count (10*9/L) | 6.48 ± 11.66 | 6.41 ± 1.70 | 6.56 ± 11.60 | 0.420 |
| Red blood cell Count (10*12/L) | 3.46 ± 0.64 | 3.44 ± 0.62 | 3.48 ± 0.67 | 0.548 |
| Hemoglobin (g/L) | 102.98 ± 17.43 | 102.49 ± 17.27 | 103.64 ± 17.69 | 0.555 |
| Red blood cell distribution width (%) | 14.95 ± 1.77 | 14.59 ± 1.45 | 15.44 ± 2.03 | <0.001 |
| Albumin (g/L) | 33.31 ± 4.90 | 33.55 ± 4.90 | 32.97 ± 4.90 | 0.291 |
| Serum creatinine (µmol/L) | 783.20 ± 184.98 | 791.12 ± 191.64 | 772.37 ± 175.58 | 0.365 |
| Uric acid (µmol/L) | 368.47 ± 84.93 | 371.03 ± 86.80 | 364.97 ± 82.48 | 0.523 |
| BNP (pg/mL) | 266.1 (109.9-641.45) |
175.65 (64.5-453.45) |
400.1 (211.6-774.2) |
0.030 |
| Direct bilirubin (µmol/L) | 3.60 (2.81-4.60) | 3.51 (2.75-4.53) | 3.76 (2.94-4.81) | 0.075 |
| Serum iron concentration (µmol/L) | 12.35 ± 5.49 | 12.51 ± 5.21 | 12.13 ± 5.85 | 0.536 |
| Iron transferrin saturation (%) | 26.89 ± 12.45 | 26.89 ± 11.78 | 26.90 ± 13.37 | 0.994 |
| Serum K (mmol/L) | 4.15 ± 0.60 | 4.14 ± 0.61 | 4.16 ± 0.59 | 0.752 |
| Serum Mg (mmol/L) | 0.88 ± 0.16 | 0.89 ± 0.17 | 0.86 ± 0.15 | 0.082 |
| Serum Ca (mmol/L) | 2.08 ± 0.20 | 2.08 ± 0.19 | 2.09 ± 0.21 | 0.667 |
| Serum P (mmol/L) | 1.74 ± 0.56 | 1.75 ± 0.53 | 1.73 ± 0.59 | 0.835 |
| Echocardiographic parameters | ||||
| LAD (mm) | 38.41 ± 6.14 | 37.65 ± 5.52 | 39.45 ± 6.77 | 0.008 |
| IVST (mm) | 11.41 ± 1.86 | 11.42 ± 1.90 | 11.41 ± 1.80 | 0.955 |
| LVPWT (mm) | 11.32 ± 3.43 | 11.34 ± 2.95 | 11.30 ± 4.01 | 0.929 |
| LVEDD (mm) | 49.92 ± 6.70 | 49.64 ± 6.08 | 50.30 ± 7.47 | 0.385 |
| LVEF (%) | 59.78 ± 8.17 | 60.37 ± 8.15 | 58.96 ± 8.14 | 0.124 |
| Septal E/e’ | 13.52 ± 5.06 | 11.05 ± 2.39 | 16.90 ± 5.74 | <0.001 |
| TAPSE (mm) | 19.98 ± 3.19 | 20.07 ± 3.41 | 19.86 ± 2.86 | 0.566 |
| PASP (mmHg) | 27.18 ± 6.62 | 26.74 ± 6.78 | 27.78 ± 6.36 | 0.157 |
| TAPSE/PASP (mm/mmHg) | 0.75 ± 0.07 | 0.76 ± 0.07 | 0.73 ± 0.07 | <0.001 |
BNP, brain natriuretic peptide; LAD, left atrial diameter; IVST, interventricular septal thickness; LVPWT, left ventricular posterior wall thickness; LVEDD, left ventricular end-diastolic diameter; LVEF, left ventricular ejection fraction; TAPSE, tricuspid annular plane systolic excursion; PASP, pulmonary artery systolic pressure.
Relationship between TASPE/PASP and AF occurrence in PD patients
Multivariable analyses revealed that RDW (OR: 1.339, 95% CI: 1.111-1.613), E/e’ (OR: 1.584, 95% CI: 1.427-1.758) and TAPSE/PASP (OR: 0.443, 95% CI: 0.271-0.725, per 0.1 mm/mmHg) were independently associated with AF occurrence (p < 0.05, respectively), as shown in Table 4.
Table 4.
Multivariate logistic regression analysis on predictors of atrial fibrillation in the peritoneal dialysis population.
| B | SE | Wald | P | OR | 95% CI | ||
|---|---|---|---|---|---|---|---|
| Age | 0.025 | 0.014 | 3.245 | 0.072 | 1.025 | 0.998 | −1.053 |
| Sex | 0.386 | 0.339 | 1.294 | 0.255 | 1.471 | 0.757 | −2.858 |
| Kt/V | −0.441 | 0.539 | 0.671 | 0.413 | 0.643 | 0.224 | −1.849 |
| BNP | 0.000 | 0.000 | 0.019 | 0.891 | 1.000 | 0.999 | −1.001 |
| RDW | 0.292 | 0.095 | 9.412 | 0.002 | 1.339 | 1.111 | −1.613 |
| LAD | 0.056 | 0.030 | 3.579 | 0.059 | 1.058 | 0.998 | −1.121 |
| Septal E/e’ | 0.460 | 0.053 | 74.789 | 0.000 | 1.584 | 1.427 | −1.758 |
| TAPSE/PASP (per 0.1 mm/mmHg) | −0.814 | 0.251 | 10.508 | 0.001 | 0.443 | 0.271 | −0.725 |
BNP, brain natriuretic peptide; RDW, red blood cell distribution width; LAD, left atrial diameter; TAPSE, tricuspid annular plane systolic excursion; PASP, pulmonary artery systolic pressure.
Predictive value of the TAPSE/PASP and mortality in PD patients
A total of 121 patients were followed up. Baseline age, BNP, RDW and septal E/e’ were significantly greater, and the TAPSE/PASP was significantly lower, in patients with AF than in those without AF (p < 0.05) in Table 5. The follow-up time ranged from 6 months to 15 months. There were 5 deaths among the PD patients with AF (7.2%) and 2 deaths in those without AF (3.8%), which demonstrated that the PD patients with AF had a higher risk of mortality than did those without AF. TAPSE/PASP was independently associated with AF occurrence (OR: 0.330, 95% CI: 0.129–0.842, per 0.1 mm/mmHg, p < 0.05) and mortality (HR: 0.458, 95% CI: 0.277–0.852, per 0.1 mm/mmHg, p < 0.05), as shown in Tables 6.1 and 6.2. The ROC analysis predicted all-cause mortality in PD patients with a cutoff of 0.715 for the TAPSE/PASP, a sensitivity of 71.1% and a specificity of 71.4% (AUC: 0.604, 95% CI: 0.393-0.815; p = 0.045). K–M analysis revealed that patients with TAPSE/PASP ratios ≤ 0.715 had a greater risk of mortality than did those with TAPSE/PASP ratios > 0.715 (Figure 2).
Table 5.
Baseline laboratory and echocardiographic parameters of follow up population.
| Overall population (n = 121) | Non-AF (n = 52) | AF (n = 69) | P | |
|---|---|---|---|---|
| Age, years | 58.94 ± 11.12 | 56.17 ± 11.78 | 61.03 ± 10.20 | 0.017 |
| Stroke (n, %) | 26 (21.5) | 9 (17.3) | 17 (24.6) | 0.377 |
| CHD (n, %) | 39 (32.2) | 12 (23.1) | 27 (39.1) | 0.078 |
| Single pool-Kt/V | 1.84 ± 0.35 | 1.85 ± 0.36 | 1.83 ± 0.34 | 0.723 |
| Aspirin (n, %) | 72 (59.5) | 28 (53.8) | 44 (63.8) | 0.350 |
| Beta-blocker (n, %) | 67 (55.4) | 24 (46.2) | 43 (62.3) | 0.097 |
| Hemoglobin (g/L) | 102.78 ± 16.70 | 102.40 ± 15.02 | 103.06 ± 17.96 | 0.832 |
| RDW (%) | 15.36 ± 1.99 | 14.72 ± 1.47 | 15.84 ± 2.20 | 0.002 |
| albumin | 33.00 ± 4.95 | 33.22 ± 4.48 | 32.83 ± 5.31 | 0.666 |
| BNP (pg/mL) | 276.6 (119.2-594.1) | 187.6 (44.9-513.8) | 338.9 (189.5-676.4) | 0.003 |
| LAD (mm) | 38.60 ± 6.21 | 38.31 ± 4.94 | 38.83 ± 7.05 | 0.651 |
| Septal E/e’ | 14.03 ± 4.39 | 11.04 ± 2.68 | 16.28 ± 4.07 | <0.001 |
| TAPSE/PASP (mm/mmHg) | 0.75 ± 0.08 | 0.77 ± 0.07 | 0.73 ± 0.07 | 0.001 |
CHD, coronary atherosclerotic heart disease; RDW, Red blood cell distribution width; BNP, brain natriuretic peptide; LAD, left atrial diameter; TAPSE, tricuspid annular plane systolic excursion; PASP, pulmonary artery systolic pressure
Table 6.1.
Multivariate logistic regression analysis on predictors of atrial fibrillation in the follow up population.
| B | SE | Wald | P | OR | 95% CI | ||
|---|---|---|---|---|---|---|---|
| Age | 0.062 | 0.027 | 5.134 | 0.023 | 1.064 | 1.008 | −1.122 |
| Sex | 0.710 | 0.598 | 1.410 | 0.235 | 2.034 | 0.630 | −6.566 |
| Kt/V | −0.770 | 0.809 | 0.907 | 0.341 | 0.463 | 0.095 | −2.259 |
| BNP | 0.000 | 0.001 | 0.003 | 0.959 | 1.000 | 0.999 | −1.001 |
| RDW | 0.319 | 0.165 | 3.741 | 0.053 | 1.376 | 0.996 | −1.902 |
| LAD | 0.022 | 0.049 | 0.199 | 0.656 | 1.022 | 0.929 | −1.125 |
| Septal E/e’ | 0.432 | 0.082 | 27.837 | 0.000 | 1.540 | 1.312 | −1.807 |
| TAPSE/PASP (per 0.1 mm/mmHg) | −1.109 | 0.478 | 5.386 | 0.020 | 0.330 | 0.129 | −0.842 |
BNP, brain natriuretic peptide; RDW, red blood cell distribution width; LAD, left atrial diameter; TAPSE, tricuspid annular plane systolic excursion; PASP, pulmonary artery systolic pressure.
Table 6.2.
Cox regression analysis on predictors of mortality in the follow up population.
| B | SE | Wald | P | HR | 95% CI | ||
|---|---|---|---|---|---|---|---|
| Age | 0.011 | 0.046 | 0.057 | 0.811 | 1.011 | 0.924 | −1.106 |
| Sex | 0.361 | 1.104 | 0.107 | 0.744 | 1.434 | 0.165 | −12.492 |
| Kt/V | 0.394 | 1.449 | 0.074 | 0.786 | 1.483 | 0.087 | −25.364 |
| BNP | 0.000 | 0.001 | 0.088 | 0.767 | 1.000 | 0.997 | −1.002 |
| RDW | −0.144 | 0.257 | 0.313 | 0.576 | 0.866 | 0.523 | −1.433 |
| LAD | 0.117 | 0.048 | 5.963 | 0.015 | 1.125 | 1.023 | −1.236 |
| Septal E/e’ | −0.106 | 0.128 | 0.680 | 0.409 | 0.899 | 0.699 | −1.157 |
| TAPSE/PASP (per 0.1 mm/mmHg) | −0.043 | 0.633 | 3.508 | 0.041 | 0.458 | 0.277 | −0.852 |
BNP, brain natriuretic peptide; RDW, red blood cell distribution width; LAD, left atrial diameter; TAPSE, tricuspid annular plane systolic excursion; PASP, pulmonary artery systolic pressure.
Figure 2.
Kaplan-Meier Curves based on the ideal cutoff (0.715) of TAPSE/PASP. The Kaplan-Meier curve for prediction of the mortality. PASP, pulmonary artery systolic pressure; TAPSE, tricuspid annular plane systolic excursion.
Discussion
The main findings of the present study are as follows: (1) TAPSE/PASP was significantly lower in patients with AF than in those without AF, and this difference was more pronounced in patients with persistent AF. (2) PD patients with AF had a greater risk of mortality than those without AF. Patients with TAPSE/PASP ratios ≤ 0.715 had a greater risk of mortality than those with TAPSE/PASP ratios > 0.715. These results suggested that the TAPSE/PASP of the RV-PA uncoupling parameter was lower in patients with AF than in those without AF and so it may be a useful factor for predicting mortality in PD patients.
Epidemiology in patients with AF with PD
AF is the most common sustained arrhythmia in the general population and is particularly common in patients with ESRD [20]. The prevalence of both AF and ESRD increases with concomitant risk factors, jointly amplifying the risk of cardiovascular mortality [21,22]. Several considerations support a hypothesized difference in AF risk between patients undergoing PD and those undergoing hemodialysis (HD). Patients undergoing HD are exposed to considerable cyclical changes in fluid and electrolyte status, with accumulation of fluid and uremic toxins, including potentially proarrhythmogenic electrolytes (potassium, calcium, magnesium) during the intradialytic interval, followed by rapid fluid removal and electrolyte shifts during the relatively short HD procedure [23]. In contrast, PD confers a more continuous removal of excess fluids and maintenance of electrolyte balance, thus putting less strain on the heart while reducing the burden of other potential AF triggers. Niu et al. [24] reported that although patients who initiated dialysis therapy via PD had a lower AF incidence than did those who received HD during the first 90 days of ESRD, there was no major difference in AF incidence thereafter. Currently, an increasing number of young dialysis patients are choosing PD because of its convenience. However, given the younger age of the PD population, the cardiovascular complications and mortality of PD have not received much attention. Therefore, it is necessary to find a more promising and inexpensive method to identify high-risk populations of PD patients early.
TAPSE/PASP values in patients with AF with PD
AF is common in patients with PH and contributes to their morbidity and mortality. AF occurs in PH patients, with a 5-year incidence ranging from 10% to 25%. Given the growing PH population, understanding the pathophysiology, clinical impact, and management of AF in PH patients is important. AF is thought to develop because of structural alterations of the right atrium caused by changes in the RV due to elevated pulmonary artery pressures. AF can subsequently worsen RV function. RV dysfunction is significantly associated with postoperative AF occurrence after cardiac surgery [25]. AF and RV dysfunction frequently coexist in ESRD patients and are independently associated with a poor prognosis. TAPSE stands for tricuspid annular plane systolic excursion, which is used to evaluate RV long-axis systolic function [26]. Patients with AF have a lower TAPSE than those with sinus rhythm in the general population [27]. RV dysfunction (by both TAPSE and right ventricular longitudinal strain) was independently associated with left ventricular systolic dysfunction and AF but not with PASP. However, the TAPSE/PASP, as a noninvasively measured index of RV–PA coupling on the basis of its correlation with invasively evaluated RV systolic elastance and pulmonary arterial elastance, is considered to be a more accurate indicator of disease severity than the TAPSE or PASP alone [28]. Previous studies have shown that, compared with healthy controls, patients with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) have a decreased TAPSE/PASP ratio, and a TAPSE/PASP < 0.48 was associated with the composite endpoint of all-cause death and HF hospitalization in HF patients [29]. Among patients with severe PH, those with a TAPSE/PASP < 0.31 had a significantly poorer prognosis than patients with a higher TAPSE/PASP [28]. Recently, a TAPSE/PASP ≤0.57 was proven to be a predictive factor of late recurrence of AF/atrial tachycardia independent of left atrial (LA) function after catheter ablation in persistent AF patients [17]. In the present study, the TAPSE and PASP were not significantly different between the AF and non-AF groups. However, the TAPSE/PASP was significantly lower in patients with AF than in those without AF. Moreover, the TAPSE/PASP was more pronounced in patients with persistent AF. PD patients with AF had a greater risk of mortality (7.2%) than did those without AF (3.8%) after an average follow-up of 12 months. Kaplan–Meier analysis demonstrated that patients with TAPSE/PASP ratios ≤ 0.715 had a greater risk of mortality than did those with TAPSE/PASP ratios > 0.715. The TAPSE/PASP cutoff value was higher than that of other studies, which may be due to the young age of the participants in this study and the exclusion of diseases such as heart failure, severe infection, and congenital heart disease.
LA remodeling is considered an important factor in the occurrence and progression of AF. Enlargement of the LA, either in diameter or volume, is a powerful prognostic marker for AF occurrence [30]. However, the results revealed no significant relationship between LA and AF occurrence. The reason for this result is that we included only PD patients without HF and excluded patients without noticeable TR signals. In addition, this was a cross-sectional study. Therefore, the number of patients with LA dysfunction included might be lower than that in previous studies.
Mechanism of RV-PA uncoupling in AF patients with PD
The mechanisms of RV-PA uncoupling and AF in PD patients are not yet fully understood. Multiple mechanisms are involved. First, inflammation is suggested to be linked to various pathological processes, such as oxidative stress, apoptosis, and fibrosis, that promote AF substrate formation [31]. Inflammation has also been reported to be associated with endothelial dysfunction and induces impaired pulmonary capillary vascular contraction [32]. Second, failure of the LV can lead to RV failure. Permanent AF is one of the most common arrhythmias in patients with depressed RV function. The frequent coexistence of HF and AF causes overlapping arrhythmia and RV dysfunction in the setting of HF. They may lead to hemodynamic compromise and a worse prognosis in patients with chronic RV failure of various etiologies [33]. In addition, there is a chronic increase in blood flow, severe anemia, fluid overload, and calcification of the pulmonary artery due to secondary hyperparathyroidism. Finally, the negative inotropic effect of an irregular rhythm is a possible contributing factor to RV-PA uncoupling [34].
Limitations
Some limitations in this study should be considered. First, this was a single-center study with inherent limitations. The results need to be confirmed in future large multicenter prospective trials. Second, no subgroup analysis of the course of AF was performed. Third, the AF condition, such as whether they showed sinus rhythm or not, of the enrolled patients was not confirmed. The condition of AF may affect the results of echocardiography. Fourth, residual renal function (RRF) was not assessed in PD patients in this study. Studies have shown that RRF decline during the first year of dialysis has a graded association with all-cause mortality among incident hemodialysis patients. The confounding factor of residual renal function on the results was not taken into account in this study. Unfortunately, the modes of peritoneal transport were not recorded. PET data are recorded every three to six months in this dialysis center, so the peritoneal transport types at baseline could not be recorded. Finally, a previous report showed that the prognostic value of the TAPSE/PASP was hemodynamically validated with right heart catheterization [35]. Invasive hemodynamic evaluation was not performed in this study. The study excluded peritoneal dialysis patients with concomitant heart failure, resulting in a significant reduction in the number of deaths at the end of the follow-up period. In addition, the follow-up time of 12 months may have been short. Further large-scale investigations are needed to confirm the results and to elucidate the pathophysiological meaning of RV-PA uncoupling in AF patients with PD.
Conclusion
The results suggested that RV-PA uncoupling TAPSE/PASP was lower in patients with AF than in those without AF. PD patients with AF had a greater risk of mortality than those without AF. The TAPSE/PASP can be a useful factor for predicting mortality in AF patients with PD, but large-scale prospective studies are needed to verify its utility.
Funding Statement
This work was supported by Scientific Research Projects of Tianjin Municipal Education Commission [2020KJ172 to Q.S.].
Disclosure statement
The authors declare that they have no conflict of interest.
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