Prognostic Implications of Right Ventricular Remodeling and Function in Patients With Significant Secondary Tricuspid Regurgitation

Abstract

Background: In patients with significant (moderate and severe) tricuspid regurgitation (TR), the decision to intervene is influenced by right ventricular (RV) size and function. RV remodeling in significant secondary TR has been underexplored. The aim of this study was to characterize RV remodeling in patients with significant secondary TR and to investigate its prognostic implications. Methods: RV remodeling was characterized by transthoracic echocardiography in 1292 patients with significant secondary TR (median age 71 [62–78]; 50% male). Four patterns of RV remodeling were defined according to the presence of RV dilation (tricuspid annulus≥40 mm) and RV systolic dysfunction (tricuspid annulus systolic excursion plane<17 mm): pattern 1, normal RV size and systolic function; pattern 2, dilated RV with preserved systolic function; pattern 3, normal RV size with systolic dysfunction; and pattern 4, dilated RV systolic dysfunction. The primary end point was all-cause mortality and the event rates were compared across the 4 patterns of RV remodeling. Results: A total of 183 (14%) patients showed pattern 1 RV remodeling; 256 (20%) showed pattern 2; 304 (24%) presented with pattern 3; and 549 (43%) had pattern 4 RV remodeling. Patients with pattern 4 RV remodeling were more frequently male; more often had coronary artery disease, worse renal function, and impaired left ventricular ejection fraction; and were more often symptomatic. Only 98 (8%) patients underwent tricuspid valve annuloplasty during follow-up. During a median follow-up of 34 (interquartile range, 0–60) months, 510 (40%) patients died. The 5-year survival rate was significantly worse in patients presenting with patterns 3 and 4 RV remodeling in comparison with pattern 1 (52% and 49% versus 70%; P =0.002 and P <0.001, respectively), and were independently associated with poor outcome on multivariable analysis. Conclusions: In patients with significant secondary TR, patients with RV systolic dysfunction have worse clinical outcome regardless of the presence of RV dilation.

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

“…More specifically, severity of right ventricular dilatation would be a critical parameter to account for as clearly established as important prognostic factor. 30 It is highly probable that patients with advanced right ventricular consequences are likely the ones that will benefit the less of tricuspid valve interventions. The most common interpretation of the discordant results of the MITRA-FR (Percutaneous Repair with the MitraClip Device for Severe Functional/Secondary Mitral Regurgitation) and COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trials is that transcatheter correction has a positive impact on survival, HF hospitalizations and quality of life in selected patients with functional MR. 31,32 Recent observational studies evaluating the impact of TR correction have provided contradictory results 33,34 and there is a critical need for randomized controlled trials aiming to evaluate the benefit and timing of therapeutic interventions for TR.…”

Late tricuspid regurgitation and right ventricular remodeling after tricuspid annuloplasty

“…Moreover, both late significant TR and RV remodeling were found to be risk factors for lower survival. In a recent echocardiographic analysis, 26 5‐year survival was significantly worse in patients presenting RV dilation or dysfunction than in those with normal RV size.…”

Right Ventricular Dysfunction Staging System for Mortality Risk Stratification in Heart Failure with Preserved Ejection Fraction

“…In a recent meta-analysis including >30,000 patients with significant TR in different cardiac scenarios, TR was associated with an increased mortality risk independent of RV failure or PH [27]. On the other hand, when a significant functional TR is present, patients with RV failure (but no RV enlargement) have worse clinical outcomes [28]. This is in line with our data, in which TAPSE/PASP prognostic value is not significantly affected by the severity of TR, whereas significant TR provides additive and complementary prognostic value to the RV-PA coupling index.…”