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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.

Objectives To define prevalence, long term outcome, and treatment standards of secondary mitral regurgitation (sMR) across the heart failure spectrum. Design Large scale cohort study. Setting Observational cohort study with data from the Viennese community healthcare provider network between 2010 and 2020, Austria. Participants 13 223 patients with sMR across all heart failure subtypes. Main outcome measures Association between sMR and mortality in patients assigned by guideline diagnostic criteria to one of three heart failure subtypes: reduced, mid-range, and preserved ejection fraction, was assessed. Results Severe sMR was diagnosed in 1317 patients (10%), correlated with increasing age (P<0.001), occurred across the entire spectrum of heart failure, and was most common in 656 (25%) of 2619 patients with reduced ejection fraction. Mortality of patients with severe sMR was higher than expected for people of the same age and sex in the same community (hazard ratio 7.53; 95% confidence interval 6.83 to 8.30, P<0.001). In comparison with patients with heart failure and no/mild sMR, mortality increased stepwise with a hazard ratio of 1.29 (95% confidence interval 1.20 to 1.38, P<0.001) for moderate and 1.82 (1.64 to 2.02, P<0.001) for severe sMR. The association between severe sMR and excess mortality was consistent after multivariate adjustment and across all heart failure subgroups (mid-range ejection fraction: hazard ratio 2.53 (95% confidence interval 2.00 to 3.19, P<0.001), reduced ejection fraction: 1.70 (1.43 to 2.03, P<0.001), and preserved ejection fraction: 1.52 (1.25 to 1.85, P<0.001)). Despite available state-of-the-art healthcare, high volume heart failure, and valve disease programmes, severe sMR was rarely treated by surgical valve repair (7%) or replacement (5%); low risk transcatheter repair (4%) was similarly seldom used. Conclusion Secondary mitral regurgitation is common overall, increasing with age and associated with excess mortality. The association with adverse outcome is significant across the entire heart failure spectrum but most pronounced in those with mid-range and reduced ejection fractions. Despite these poor outcomes, surgical valve repair or replacement are rarely performed; similarly, low risk transcatheter repair, specifically in the heart failure subsets with the highest expected benefit from treatment, is seldom used. The current data suggest an increasing demand for treatment, particularly in view of an expected increase in heart failure in an ageing population.

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