Impact of New Grading System and New Hemodynamic Classification on Long-Term Outcome in Patients With Severe Tricuspid Regurgitation

Background: A new grading of tricuspid regurgitation (TR) beyond severe has been proposed. However, few studies assessing the validity of such a new grading scheme of TR have been conducted. Therefore, we evaluated associations of TR grades beyond severe with patient outcome and hemodynamics. Methods: We retrospectively studied patients who underwent 2-dimensional echocardiography and were diagnosed with severe TR between January 2014 and December 2015. According to the vena contracta width of TR (VC), the patients were classified into 2 groups: VC under 14 mm (VC<14 mm) and VC 14 mm or greater (VC >= 14 mm). Hemodynamic parameters were estimated by echocardiography and were obtained by right heart catheterization. Cardiovascular events were defined as cardiovascular death or admission for heart failure. Results: A total of 679 patients (mean 72 +/- 17 years, 56% women) were included. During follow-up (median, 158 days; range, 29-891), 210 patients experienced cardiovascular events. By multivariate analysis, VC >= 14 mm and left ventricular ejection fraction were independent predictors of cardiovascular events (hazard ratio, 1.57 [1.06-2.33]; hazard ratio, 0.99 [0.98-0.99], respectively). Patients with VC >= 14 mm had significantly lower cardiac index (median, 1.8 versus 2.1 L/min per m(2), P=0.001) and a higher prevalence of right atrial pressure 15 mm Hg (74% versus 60%, P<0.001) on echocardiography. Also, right heart catheterization confirmed higher right atrial pressure in patients with VC >= 14 mm than those with VC<14 mm (16 +/- 8 versus 12 +/- 6 mm Hg, P=0.004). The new subset classification developed by cardiac index and right atrial pressure both on echocardiography predicted cardiovascular events (Log-rank P<0.001). Conclusions: The relationship of VC >= 14 mm to adverse outcome and poor hemodynamics showed the clinical relevance and need of a new grading system beyond severe. The new hemodynamic subset classification provides additional prognostic value for cardiovascular events in patients with severe TR.

Automated summary

This study evaluated the impact of a new TR grading scheme on patient outcomes and hemodynamics, showing that VC >= 14 mm was significantly associated with cardiovascular events and poorer hemodynamic parameters. The new hemodynamic subset classification based on cardiac index and right atrial pressure predicted cardiovascular events in severe TR patients, providing additional prognostic value.