Epiphenomenon or Prognostically Relevant Interventional Target? A Novel Proportionality Framework for Severe Tricuspid Regurgitation

BackgroundTricuspid regurgitation (TR) frequently develops in patients with long-standing pulmonary hypertension, and both pathologies are associated with increased morbidity and mortality. This study aimed to improve prognostic assessment in patients with severe TR undergoing transcatheter tricuspid valve intervention (TTVI) by relating the extent of TR to pulmonary artery pressures. Methods and ResultsIn this multicenter study, we included 533 patients undergoing TTVI for moderate-to-severe or severe TR. The proportionality framework was based on the ratio of tricuspid valve effective regurgitant orifice area to mean pulmonary artery pressure. An optimal threshold for tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio was derived on 353 patients with regard to 2-year all-cause mortality and externally validated on 180 patients. Patients with a tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio <= 1.25 mm(2)/mm Hg (defining proportionate TR) featured significantly lower 2-year survival rates after TTVI than patients with disproportionate TR (56.6% versus 69.6%; P=0.005). In contrast with patients with disproportionate TR (n=398), patients with proportionate TR (n=135) showed more pronounced mPAP levels (37.9 +/- 9.06 mm Hg versus 27.9 +/- 8.17 mm Hg; P<2.2x10(-16)) and more severely impaired right ventricular function (tricuspid annular plane systolic excursion: 16.0 +/- 4.11 versus 17.0 +/- 4.64 mm; P=0.012). Moreover, tricuspid valve effective regurgitant orifice area was smaller in patients with proportionate TR when compared with disproportionate TR (0.350 +/- 0.105 cm(2) versus 0.770 +/- 0.432 cm(2); P<2.2x10(-16)). Importantly, proportionate TR remained a significant predictor for 2-year mortality after adjusting for demographic and clinical variables (hazard ratio, 1.7; P=0.006). ConclusionsThe proposed proportionality framework promises to improve future risk stratification and clinical decision-making by identifying patients who benefit the most from TTVI (disproportionate TR). As a next step, randomized controlled studies with a conservative treatment arm are needed to quantify the net benefit of TTVI in patients with proportionate TR.

Automated summary

This study aimed to improve prognosis assessment in patients with severe tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve intervention (TTVI) by relating the extent of TR to pulmonary artery pressures. The study found that patients with a tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio <= 1.25 mm(2)/mm Hg had significantly lower 2-year survival rates after TTVI compared to patients with a higher ratio. Furthermore, patients with a lower ratio had higher pulmonary artery pressures and more severely impaired right ventricular function.