Echocardiographic Assessment of Right Ventricular–Pulmonary Arterial Coupling in Heart Failure: Prognostic Insights from a Systematic Review

Background: Prognostic heterogeneity in heart failure (HF) is substantial and not fully captured by conventional left-sided echocardiographic parameters. Growing evidence highlights the importance of right ventricular–pulmonary arterial (RV–PA) interaction in HF pathophysiology and outcomes. The echocardiographic tricuspid annular plane systolic excursion-to-systolic pulmonary artery pressure (TAPSE/sPAP) ratio has been proposed as a simple noninvasive surrogate of RV–PA coupling, yet its prognostic value across the HF spectrum remains incompletely defined. Methods: This systematic review followed PRISMA guidelines and was registered in INPLASY. PubMed, Scopus, and EMBASE were searched from inception through January 2026 for observational studies evaluating the prognostic value of TAPSE/sPAP in adult patients with HF. Study selection, data extraction, and risk-of-bias assessment were performed independently by two reviewers. Owing to substantial heterogeneity, a qualitative synthesis with weighted pooled descriptive statis- tics was performed. Results: Fifteen observational studies including 5389 patients were analyzed, with a median follow-up of approximately 1.9 years, ranging from in-hospital outcomes to long-term follow-up of up to 15 years. Study populations encompassed a wide range of HF phenotypes and clinical settings, including acute and chronic HF, preserved and reduced ejection fraction, valvular heart disease, infiltrative cardiomyopathies, and advanced HF. Across studies, reduced TAPSE/sPAP was generally associated with adverse outcomes, including all-cause mortality and HF-related events, with reported hazard ratios ranging from approximately two- to five-fold. Prognostically relevant TAPSE/sPAP cut-off values tended to cluster within a relatively narrow range, with most thresholds between 0.36 and 0.40 and a weighted median of approximately 0.36. When reported, TAPSE/sPAP showed favorable discriminative performance for adverse outcomes. Overall methodologi- cal quality was predominantly fair. Conclusions: Across heterogeneous HF populations, impaired TAPSE/sPAP appears to be a consistent marker of adverse prognosis. These findings support TAPSE/sPAP as a practical, noninvasive indicator of RV–PA uncoupling that may contribute to risk stratification and phenotyping in heart failure. Prospective studies focusing on specific HF phenotypes are needed to clarify its role in longitudinal monitoring and therapeutic decision-making.