5937Natural history of functional tricuspid regurgitation: implications of quantitative doppler assessment

Abstract

Objectives To establish the prognostic value of quantitative measures of functional tricuspid regurgitation (TR) severity i.e. effective regurgitant orifice area (EROA) and regurgitant volume. Methods 382 patients with HFrEF on guideline-directed medical therapy were enrolled and TR EROA as well as regurgitant volume by Doppler/2D-echocardiography were assessed. All-cause mortality was defined as the primary study endpoint. Results Quantitative metrics of TR severity were consistently associated with mortality with a HR of 1.27 (95% CI 1.13–1.42, P<0.001) for the EROA and of 1.29 (95% CI 1.14–1.45, P<0.001) for the regurgitant volume (Figure 1, Panels A and B). Results remained unchanged after bootstrap- or clinical confounder-based adjustment. A spline curve pattern illustrates the association with mortality with thresholds for the EROA≥0.2cm2, and the regurgitant volume≥20ml with sustained excess mortality thereafter (Figure 1 Panels C-D). Figure 1. Panels A–D Conclusions This large-scale study demonstrates the prognostic value of quantitative measures of TR severity in HFrEF. Thresholds for EROA and TR regurgitant volume associated with mortality fall within current ranges defining non-severe TR. This may potentially impact therapeutic decision making particularly timing of intervention.

Impact of tricuspid regurgitation on survival in patients with heart failure: a large electronic health record patient‐level database analysis

“…However, this study was performed on a selected population, predominantly men, and more severe TR was associated with lower LVEF, leaving the intrinsic effect of TR on survival in doubt. Following this seminal paper, several studies also suggested that TR was associated with worse outcomes, 3,6,8,9 while other studies did not find such association 10,11 . Recently, a meta‐analysis from 70 studies encompassing 32 601 patients concluded to an independent association between moderate or severe TR and mortality, 21 but could not eliminate the effect of comorbidities on mortality.…”

“…TR is highly prevalent 5,6 but the impact of TR on survival in patients with HF is disputed. While recent studies suggested a link between TR and worse outcomes, predominantly in the context of severely reduced systolic function, 3,5–9 other studies found no independent association with survival 10,11 . Furthermore, most studies on functional TR have been modest in size, have focused on HF with reduced ejection fraction (HFrEF) and have not considered HF as a global entity inclusive of preserved ejection fraction (HFpEF) and have originated from single tertiary referral centres with inherent referral bias, but also with expert interpretation of TR severity, a notoriously complex evaluation 12 .…”

Uncertainties and challenges in surgical and transcatheter tricuspid valve therapy: a state-of-the-art expert review

“…42 Moreover, recent publications have shown that the current cut-off values for quantitative parameters used to assess TR severity are inadequate to quantify the burden on the RV and it is likely that lower threshold values of effective regurgitant orifice area (EROA) and regurgitant volume define severe TR. 43 This finding was also supported by the study of Bartko et al 44 showing a significant increase in mortality and morbidity for EROA > _0.2 cm 2 and regurgitant volume > _20 mL in HF patients with reduced ejection fraction. This may potentially impact the therapeutic decision-making, particularly timing for intervention.…”

Role of 3-Dimensional Echocardiography in the Comprehensive Evaluation of the Tricuspid Valve in Patients With Tricuspid Regurgitation

“…7 Indeed, TR was also found to be heterogeneous in survival according to its cause 8 and severity. 9 Overall, however, very high mortality…”