Functional tricuspid regurgitation of degenerative mitral valve disease: a crucial determinant of survival

Abstract

Aims To assess functional tricuspid regurgitation (FTR) determinants, consequences, and independent impact on outcome in degenerative mitral regurgitation (DMR). Methods and results All patients diagnosed with isolated DMR 2003–2011, with structurally normal tricuspid leaflets, prospective FTR grading and systolic pulmonary artery pressure (sPAP) estimation by Doppler echocardiography at diagnosis were identified and long-term outcome analysed. The 5083 DMR eligible patients [63 ± 16 years, 47% female, ejection fraction (EF) 63 ± 7%, and sPAP 35 ± 13 mmHg] presented with FTR graded trivial in 45%, mild in 37%, moderate in 15%, and severe in 3%. While pulmonary hypertension (PHTN-sPAP ≥ 50 mmHg) was the most powerful FTR severity determinant, other strong FTR determinants were older age, female sex, lower left ventricle EF, DMR, and particularly atrial fibrillation (AFib) (all P ≤ 0.002). Functional tricuspid regurgitation moderate/severe was independently linked to more severe clinical presentation, more oedema, lower stroke volume, and impaired renal function (P ≤ 0.01). Survival (95% confidence interval) throughout follow-up [70% (69–72%) at 10 years] was strongly associated with FTR severity [82% (80–84%) for trivial, 69% (66–71%) for mild, 51% (47–57%) for moderate, and 26% (19–35%) for severe, P < 0.0001]. Excess mortality persisted after comprehensive adjustment [adjusted hazard ratio 1.40 (1.18–1.67) for moderate FTR and 2.10 (1.63–2.70) for severe FTR, P ≤ 0.01]. Excess mortality persisted adjusting for sPAP/right ventricular function (P < 0.0001), by matching [adjusted hazard ratios 2.08 (1.50–2.89), P < 0.0001] and vs. expected survival [risk ratio 1.79 (1.48–2.16), P < 0.0001]. Within 5-year of diagnosis valve surgery was performed in 73% (70–75%) and 15% (13–17%) of severe and moderate DMR and in only 26% (19–34%) and 6% (4–8%) of severe and moderate FTR. Valvular surgery improved outcome without alleviating completely higher mortality associated with FTR (P < 0.0001). Conclusion In this large DMR cohort, FTR was frequent and causally, not only linked to PHTN but also to other factors, particularly AFib. Higher FTR severity is associated at diagnosis with more severe clinical presentation. Long term, FTR is independently of all confounders, associated with considerably worse mortality. Functional tricuspid regurgitation moderate and even severe is profoundly undertreated. Thus careful assessment, consideration for tricuspid surgery, and testing of new transcatheter therapy is warranted.

Concomitant tricuspid regurgitation severity and its secondary reduction determine long-term prognosis after transcatheter mitral valve edge-to-edge repair

“…A meta-analysis of 1,328 TAVI and 1, 001 MitraClip ® patients concluded that moderate-to-severe TR was a relevant determinant for increased mortality in left ventricular valvular heart disease [29]. Whether observed differences in survival between FMR and DMR patients in our study are subject to statistical bias, published data on surgically or medically treated DMR patients concluded that concomitant TR could also be a relevant determinant of survival in these patients [8] -or are caused by the completely different pathophysiology of MR etiologies as well as an impact of post-interventional changes in TMVR patients, has to be addressed by future analyses.…”

“…In 35% of the patients, concomitant TR was reduced. Recently, a large registry comprising more than 5, 000 DMR patients demonstrated that severity of concomitant TR is a relevant inverse predictor of long-term survival of these patients regardless of a medical or surgical management strategy regarding MR [8]. While symptomatic and prognostic benefits have been recently proven for edge-to-edge TMVR for FMR in a multi-centric prospective trial in the US [19], the discussion on optimal patient selection is still on-going, since another prospective trial with similar design did not confirm these results [20].…”

“…At the time of the index procedure, mean age was 78. 5 8.1% of the treated patients. Regarding dyspnoea, 99.4% had been symptomatic and 89.2% were graded as NYHA classes III/IV.…”

“…Relevant TR can be detected in 30-50% of patients with MR [5,6]. TR was shown to be an individual predictor for adverse prognosis in large registries [7] also in the context of MR [8]. Contemporarily, only a minority of TR patients are treated up to now [9].…”

Tricuspid Regurgitation in Left Ventricular Systolic Dysfunction: Marker or Target?

“…The long-time accepted idea that tricuspid regurgitation (TR) is a benign valvular condition has been deeply rebutted by almost one decade of insights into its epidemiological and clinical implication. While trivial TR is a common finding during routine echocardiography examination of asymptomatic subjects and is considered almost a physiological condition (1), most recent data suggest that at least moderate TR is a frequent condition too, worsening mid and long-term survival, particularly in patients >75 years old, and in those suffering from left ventricular systolic dysfunction (LVSD) (2)(3)(4)(5).…”