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

Vera Fortmeier, Mark Lachmann, Maria I. Körber, Matthias Unterhuber, Moritz von Scheidt, Elena Rippen, Gerhard Harmsen, Muhammed Gerçek, Kai Peter Friedrichs, Fabian Roder, Tanja K. Rudolph, Shinsuke Yuasa, Michael Joner, Karl Ludwig Laugwitz, Stephan Baldus, Roman Pfister, Philipp Lurz, Volker Rudolph

Research output: Contribution to journalArticlepeer-review

10 Citations (Scopus)


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 × 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.

Original languageEnglish
Pages (from-to)381-394
Number of pages14
JournalJACC: Cardiovascular Interventions
Issue number4
Publication statusPublished - 2022 Feb 28


  • artificial intelligence
  • pulmonary hypertension
  • transcatheter tricuspid valve intervention
  • tricuspid regurgitation

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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