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.

Background In patients with significant functional tricuspid regurgitation, timely detection of right ventricular (RV) dysfunction with conventional 2-dimensional echocardiography is challenging, whereas speckle-tracking echocardiography RV free wall longitudinal strain has been proposed as better prognosticator. We evaluated the prevalence and prognostic value of impaired RV free wall longitudinal strain in patients with significant functional tricuspid regurgitation, in comparison with tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC). Methods Eight hundred ninety-six patients (51.3% men, 71 years [62–78 years]) with significant functional tricuspid regurgitation were divided according to the presence of RV dysfunction (defined as TAPSE <17 mm, FAC <35%, and RV free wall longitudinal strain >−23%) and were followed for the occurrence of all-cause mortality. Results RV free wall longitudinal strain identified the highest percentage of RV dysfunction (84.9%), in comparison to FAC (48.5%) and TAPSE (71.7%). During a median follow-up of 2.8 years (1.3–5.4 years), 443 (49.4%) patients died. Compared with survivors, nonsurvivors showed worse RV systolic dysfunction (FAC=36.5±12.7% versus 33.9±11.8%, P =0.001; TAPSE=15.4±5.0 versus 14.0±4.5 mm, P <0.001; RV free wall longitudinal strain=−15.9±7.5% versus −12.9±6.8%, P <0.001). Cumulative event-free survival was significantly worse in patients with decreased FAC, decreased TAPSE, and impaired RV free wall longitudinal strain. On multivariate analysis, RV free wall longitudinal strain was independently associated with all-cause mortality and incremental to FAC and TAPSE. Conclusions In significant tricuspid regurgitation, impaired RV free wall longitudinal strain identifies higher rates of RV dysfunction and is associated with worse outcome beyond conventional echocardiographic parameters of RV systolic function.

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Background: Atrial functional tricuspid regurgitation (atrial TR) has received growing recognition as a TR entity with a distinct cause owing to its independence from valvular tethering as the predominant mechanism underlying TR. However, characterization of atrial TR varies, and a universal definition is lacking. Methods: In total, 651 patients with significant functional TR were analyzed, including 438 conservatively treated individuals and 213 patients who received transcatheter tricuspid valve repair (TTVR). Based on a clustering approach, we defined atrial TR as tricuspid valve (TV) tenting height ≤10 mm, midventricular right ventricular diameter ≤38 mm, and left ventricular ejection fraction ≥50%. Results: Patients with atrial TR were more often females, had higher right ventricular fractional area change, higher left ventricular ejection fraction, and lower LV end-diastolic diameter, TV tenting area and height, lower right ventricular and tricuspid annular size, enlarged, but lower right atrial area and lower TV effective regurgitant orifice area (all P <0.05). Patients with atrial TR had significantly better long-term survival than non-atrial TR in the conservatively treated TR cohort ( P <0.01, n=438). Atrial TR was independently associated with a lower rate of the combined end point of mortality and heart failure hospitalization at 1-year follow-up in the TTVR cohort (hazard ratio, 0.39; P <0.05, n=213). TR degree was significantly reduced after TTVR in non-atrial and atrial TR ( P <0.01). Functional parameters significantly improved following TTVR independent of TR cause ( P <0.05). Conclusions: An echocardiography-based atrial TR definition is associated with prognostic relevance in patients with functional TR in conservatively treated TR and after TTVR.

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The prognostic impact of isolated tricuspid regurgitation (TR) in patients with atrial fibrillation (AF) has not been investigated. The purpose of this study was to investigate the prognostic implications of significant isolated TR in AF patients without left-sided heart disease, pulmonary hypertension, or primary structural abnormalities of the tricuspid valve. A total of 63 AF patients with moderate and severe TR were matched for age and gender to 116 AF patients without significant TR. Patients were followed for the occurrence of all-cause mortality, hospitalization for heart failure and stroke. Patients with significant isolated TR (mean age 71 § 8 years, 57% men) more often had paroxysmal AF as compared with patients without TR (mean age 71 § 7 years, 60% men) (60% vs 43%, p = 0.028). In addition, right atrial size and tricuspid annular diameter were significantly larger in patients with significant isolated TR compared with their counterparts. During follow-up (median 62 [34 to 95] months), 53 events for the combined endpoint occurred. One-and 5-year event-free survival rates for patients with significant isolated TR were 76% and 56%, compared with 92% and 85% for patients without significant TR, respectively (Log rank Chi-Square p <0.001). The presence of significant isolated TR was independently associated with the combined endpoint (hazard ratio, 2.853; 95% confidence interval, 1.458 to 5.584; p = 0.002). In conclusion, in the absence of left-sided heart disease and pulmonary hypertension, significant isolated TR is independently associated with worse event-free survival in patients with AF.

Butcher SC, Fortuni F, Dietz MF, Prihadi EA, van der Bijl P, Ajmone Marsan N, et al. Renal function in patients with significant tricuspid regurgitation: pathophysiological mechanisms and prognostic implications. J Intern Med 2021;Background. The pathophysiological mechanisms linking tricuspid regurgitation (TR) and chronic kidney disease (CKD) remain unknown. This study aimed to determine which pathophysiological mechanisms related to TR are independently associated with renal dysfunction and to evaluate the impact of renal impairment on long-term prognosis in patients with significant (≥ moderate) secondary TR.Methods. A total of 1234 individuals (72 [IQR 63-78] years, 50% male) with significant secondary TR were followed up for the occurrence of all-cause mortality and the presence of significant renal impairment (eGFR of <60 mL min À1 1.73 m À2 ) at the time of baseline echocardiography.Results. Multivariable analysis demonstrated that severe right ventricular (RV) dysfunction (TAPSE < 14 mm) was independently associated with the presence of significant renal impairment (OR 1.49, 95% CI 1.11 to 1.99, P = 0.008). Worse renal function was associated with a significant reduction in survival at 1 and 5 years (85% vs. 87% vs. 68% vs. 58% at 1 year, and 72% vs. 64% vs. 39% vs. 19% at 5 years, for stage 1, 2, 3 and 4-5 CKD groups, respectively, P < 0.001). The presence of severe RV dysfunction was associated with reduced overall survival in stage 1-3 CKD groups, but not in stage 4-5 CKD groups.Conclusions. Of the pathophysiological mechanisms identified by echocardiography that are associated with significant secondary TR, only severe RV dysfunction was independently associated with the presence of significant renal impairment. In addition, worse renal function according to CKD group was associated with a significant reduction in survival.