The prevalence of tricuspid regurgitation (TR) is significant; its prognosis is well known, and severe TR stages are associated with higher mortality and hospitalization for cardiac failure (CF). Seeing as valve disease tends to evolve over time, in advanced stages, we usually check on patients at specified intervals for early identification of potential hemodynamic complications and clinical consequences.
The purpose of this study, carried out in nice centers across Spain, was to assess TR progression indicators and predictors to understand its prognostic impact. It prospectively included consecutive patients with at least moderate TR according to ECG, excluding those with prior tricuspid intervention, active endocarditis or congenital cardiomyopathy involving the tricuspid valve. The study gathered data from 1442 patients who were followed up to 2 years.
TR etiology was classified into: secondary to left-heart disease, to right ventricular disease, related to precapillary pulmonary hypertension, related to other implantable devices, isolated, and secondary to other causes. Severity was graded as mild, moderate, severe, massive and torrential. Patients experiencing changes in severity between checkups were called progressors, non-progressors and regressors.
Mean age was 76.9, and 66% were women. At kickoff, 69% presented moderate TR, 26.4% severe, 4% massive and 0.6% torrential. Mean followup was 2.3 years. Assessed main points included hospitalization for CF, unplanned tricuspid valve interventions, cardiovascular mortality and all-cause mortality.
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19% of the cohort experienced progression of at least one degree, while there were no changes in 43% during followup. Similarly, prior studies had shown high morbidity, with 72% hypertension (HTA), 50% atrial fibrillation and 35% chronic kidney failure (CKF).
As regards symptoms, 61% were in functional class II and 32.6% presented congestive symptoms. Patients catalogued as progressors (19%) were generally older, and had higher prevalence of chronic kidney disease.
Significant TR was predominantly secondary to left heart disease (59.7%), followed by right ventricle related TR (9.9%) and isolated TR (9%). Left side compromise was not associated to increased progression or end point events.
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33% presented high pulmonary hypertension, which increased hospitalization risk for cardiac failure. ECG showed atrioventricular coupling deterioration at severe stages, and ≥ moderate patients experienced 4.9%, 10.1% and 24.8% progression rate at one, two and three years respectively.
During followup, there was 11% mortality, 3.8% of cardiovascular cause. 22.3% of patients were hospitalized for cardiac failure, while 1.6% required intervention for TR. Cardiovascular mortality and cardiac failure end points were higher among progressors vs. non-progressors and regressors (36.7% vs 23.1% vs 24.2%, P < 0.001).
Conclusions
This study on predictors and progression indications of TR did not show a linear progression pattern for TR. Patients with significant TR presented more comorbidities, which speaks of its complex management. The presence of pulmonary hypertension in patients with TR was associated with worse prognosis at mid-term.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Determinants of Tricuspid Regurgitation Progression and Its Implications for Adequate Management.
Reference: Arteagoitia Bolumburu, A, Monteagudo Ruiz, J, Mahia, P. et al. Determinants of Tricuspid Regurgitation Progression and Its Implications for Adequate Management. J Am Coll Cardiol Img. null2023, 0 (0). https://doi.org/10.1016/j.jcmg.2023.10.006.
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