The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype

Abstract

AimWe sought to evaluate the differences in prognosis between the atrial (A-STR) and the ventricular (V-STR) phenotypes of secondary tricuspid regurgitation.Materials and methodsConsecutive patients with moderate or severe STR referred for echocardiography were enrolled. A-STR and V-STR were defined according to the last ACC/AHA guidelines criteria. The primary endpoint was the composite of all-cause death and heart failure (HF) hospitalizations.ResultsA total of 211 patients were enrolled. The prevalence of A-STR in our cohort was 26%. Patients with A- STR were significantly older and with lower NYHA functional class than V-STR patients. The prevalence of severe STR was similar (28% in A-STR vs. 37% in V-STR, p = 0.291). A-STR patients had smaller tenting height (TH) (10 ± 4 mm vs. 12 ± 7 mm, p = 0.023), larger end-diastolic tricuspid annulus area (9 ± 2 cm2 vs. 7 ± 6 cm2/m2, p = 0.007), smaller right ventricular (RV) end-diastolic volumes (72 ± 27 ml/m2 vs. 92 ± 38 ml/m2; p = 0.001), and better RV longitudinal function (18 ± 7 mm vs. 16 ± 6 mm; p = 0.126 for TAPSE, and −21 ± 5% vs. −18 ± 5%; p = 0.006, for RV free-wall longitudinal strain, RVFWLS) than V-STR patients. Conversely, RV ejection fraction (RVEF, 48 ± 10% vs. 46 ± 11%, p = 0.257) and maximal right atrial volumes (64 ± 38 ml/m2 vs. 55 ± 23 ml/m2, p = 0.327) were similar between the two groups. After a median follow-up of 10 months, patients with V-STR had a 2.7-fold higher risk (HR: 2.7, 95% CI 95% = 1.3–5.7) of experiencing the combined endpoint than A-STR patients. The factors related to outcomes resulted different between the two STR phenotypes: TR-severity (HR: 5.8, CI 95% = 1, 4–25, P = 0.019) in A-STR patients; TR severity (HR 2.9, 95% CI 1.4–6.3, p = 0.005), RVEF (HR: 0.97, 95% CI 0.94–0.99, p = 0.044), and RVFWLS (HR: 0.93, 95% CI 0.85–0.98, p = 0.009) in V-STR.ConclusionAlmost one-third of patients referred to the echocardiography laboratory for significant STR have A-STR. A-STR patients had a lower incidence of the combined endpoint than V-STR patients. Moreover, while TR severity was the only independent factor associated to outcome in A-STR patients, TR severity and RV function were independently associated with outcome in V-STR patients.

Contemporary insights into the epidemiology, impact and treatment of secondary tricuspid regurgitation across the heart failure spectrum

“…Interestingly, this effect was independent of LV function, as severe sTR was not a significant predictor of mortality in any HF subtype for patients with severely reduced RV function (online supplementary Figure S3-S5). Additionally, the phenotype of sTR can affect survival, [23][24][25] but in-depth analysis according to HF subgroups is currently lacking. mostly with concomitant left-sided surgery.…”

Three-dimensional echocardiography of the tricuspid valve

“…For example, 3DTTE has been shown to be effective in evaluating the size and function of the right atrium and right ventricle and their association with TR etiology and severity ( 32 , 33 ). Differentiating the etiology of STR has clinical relevance, particularly as the two have different natural histories, with atrial STR exhibiting a more favorable clinical course and response to TTVR ( 34 , 35 ) Additionally, en face visualization of TV leaflets provides further clarity into the size, shape, and location of leaflet defects, including causes congenital in nature, identifying vegetations in endocarditis, localizing prolapse of individual TV leaflets, assessing sites of TV chordae rupture, characterizing TV tumors, and evaluating valvular and atrial thrombi ( 23 , 36 – 39 ). Studying the degree of TR associated with CIED implantation has revealed mixed results, and this has been attributed to the limited role of 2D TTE in evaluating these patients, where device leads are fully visualized traversing the TVA in only 15% of patients ( 40 , 41 ).…”

“…For example, 3DTTE has been shown to be effective in evaluating the size and function of the right atrium and right ventricle and their association with TR etiology and severity (32, 33). Differentiating the etiology of STR has clinical relevance, particularly as the two have different natural histories, with atrial STR exhibiting a more favorable clinical course and response to TTVR (34,35) Additionally, en face visualization of TV leaflets provides further clarity into the size, shape, and location of leaflet defects, including causes congenital in nature, identifying vegetations in endocarditis, localizing prolapse of individual TV leaflets, assessing sites of TV…”

Pulmonary Hypertension Associated with Left Heart Disease

“…However, the atrial secondary TR is generally associated with more favorable outcome than the ventricular secondary TR. 63…”

“…Among right-sided VHD, TR is gaining attention due to (1) advances in imaging techniques in the last decades, which have allowed better characterization and understanding of the complex morphology and function of the right heart and of the tricuspid valve apparatus 58 59 ; (2) increasing evidence of the adverse outcome and worse symptoms associated with the development of TR 63 ; (3) technological development of transcatheter, minimally invasive devices, to repair or replace the tricuspid valve. 107…”