Survival in Patients with Tricuspid Regurgitation According to Clinical and Echocardiographic Variables (Clusters)

Survival analysis of patients with tricuspid regurgitation grouped according to comorbidities and echocardiographic variables.

For many years, the tricuspid was classified as the “forgotten valve,” due to the scarce possibility of treatment beyond symptom control in patients with heart failure. However, in recent years, there has been an improvement in the treatment of the valve per se, either through surgical intervention or percutaneous devices for patients at high surgical risk.

Sobrevida en pacientes con insuficiencia tricuspídea según variables clínicas y ecocardiográficas (Clusters)

Nevertheless, determining whether a patient is eligible for treatment remains a difficult task. Nowadays, there are more specific pathophysiological classifications, establishing types such as atrial functional, ventricular functional, related to implantable devices, or primary (pure valvular).

The aim of this study, conducted by a working group from Mayo Clinic, was to identify different common phenotypes in tricuspid regurgitation through a clustering analysis and to determine whether the presence of these phenotypes is associated with a different prognosis.

The study included 13,611 consecutive patients with tricuspid regurgitation (TR) ≥ moderate between January 2004 and April 2019. Demographic, clinical, and echocardiographic variables were identified and divided into 5 types (clusters).

The primary endpoint (PEP) was all-cause mortality.

Mean patient age was 72.5 ± 13.4 years; 55.8% of subjects were female. In terms of severity, 55.7% had moderate TR; 19.8%, moderate to severe TR, and 24.5%, severe TR. Atrial fibrillation (AF) was present in 57.5% of patients, with an average NT-ProBNP of 2738 pg/mL.

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Cluster 1 encompassed patients with low-risk TR (reference group). Most subjects were female (65.8%), with moderate TR (74.8%), a slightly dilated right ventricle (RV) (only 10% of cases), and RV pressure ≥50 mmHg in 30% of cases, with normal left ventricular (LV) filling pressures.

Cluster 2 had the most patients and was categorized as the highest risk; moderate to severe TR was observed in 59% of patients, RV dilatation in 45.7%, and diuretic use in 68.3%. About 53% of subjects had some other type of left valvulopathy, while LV filling pressures were elevated (E/e’=20±11).

Cluster 3 included patients with predominantly pulmonary disease—as 88.5% had COPD—, and with the etiology of TR being identified due to pulmonary hypertension secondary to pneumopathy. Increased RV systolic pressure values ≥50 mmHg were observed in 65% of cases, with LV filling pressures at borderline values (E/e’=14.9).

Cluster 4 were patients labeled as “coronary,” with atherosclerotic disease in 92.3% of cases. Most subjects were male (61.9%), with larger LV diameters (DFD 54.6±10.1mm) and the lowest level of ejection fraction (41.8%±17.8%).

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Cluster 5 included patients with renal dysfunction, mainly secondary to diabetes and arterial hypertension (74%). These were the youngest patients (mean age 66 years) and 47.7% experienced moderate to severe TR. They also had high filling pressures, with a preserved systolic volume index in 62.4% of cases.

During a mean follow-up period of 6.5 years, 7823 patients died. In the Kaplan-Meier unadjusted survival analysis, Cluster 1 had the lowest mortality (38%). In turn, mortality in Cluster 2 was 68% (hazard ratio [HR]: 2.22; p < 0.0001), in Cluster 4 was 67% (HR: 2.19; p < 0.0001), in Cluster 3 was 71% (HR: 2.22; p < 0.0001), and in Cluster 5 was 83% (HR: 3.48; < 0.0001). This mortality difference was maintained when adjusting for TR grade, comorbidities, TRIO score, and MELD.


Through cluster analysis, different phenotypes were identified for patients with moderate to severe TR. Thus, it was observed that each of these groups had different mortality rates. These data could help to identify patients who have a greater probability of benefit when choosing treatment, independently of the primary or secondary etiology of their valvular heart disease.

Dr. Omar Tupayachi

Dr. Omar Tupayachi.
Member of the Editorial Board of

Original Title: The 5 Phenotypes of Tricuspid Regurgitation: Insight From Cluster Analysis of Clinical and Echocardiographic Variables.

Reference: Anand, Vidhu et al. “The 5 Phenotypes of Tricuspid Regurgitation: Insight From Cluster Analysis of Clinical and Echocardiographic Variables.” JACC. Cardiovascular interventions vol. 16,2 (2023): 156-165. doi:10.1016/j.jcin.2022.10.055.

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