Clinical Outcome of Isolated Tricuspid Regurgitation

Study Questions:

What outcomes are associated with isolated tricuspid regurgitation (TR)?

Methods:

In a retrospective review of echocardiograms from 1995 to 2005, patients were identified with isolated TR (defined as holosystolic and functional TR in the absence of pulmonary hypertension, any intrinsic tricuspid valve disease, left ventricular dysfunction, concomitant valve disease, pacemaker or defibrillator leads, and congenital or pericardial disease). Patients with severe comorbid diseases were excluded. TR was assessed qualitatively and quantitatively using proximal isovelocity surface area. A long-term outcome analysis was conducted; endpoint events were mortality and cardiovascular events (cardiac death including sudden death, and congestive heart failure) under medical management.

Results:

The study involved 353 patients with isolated TR (age 70 years; 33% male; ejection fraction 63%; all with right ventricular systolic pressure <50 mm Hg). Severe isolated TR was diagnosed in 76 patients (21.5%) qualitatively and 68 patients (19.3%) by quantitative criteria (effective regurgitant orifice [ERO] ≥40 mm2). Ten-year survival and cardiac event rates were 63 ± 5% and 29 ± 5%. Severe isolated TR independently predicted higher mortality (adjusted hazard ratio, 1.78 [1.10-2.82]; p = 0.02 for qualitative definition and 2.67 [1.66-4.23] for an ERO ≥40 mm2, p < 0.0001). The addition of grading by quantitative criteria in nested models eliminated the significance of the qualitative grading and improved the model prediction (p < 0.001 for survival and p = 0.02 for cardiac events). The 10-year survival rate was lower with an ERO ≥40 mm2 versus <40 mm2 (38 ± 7% vs. 70 ± 6%; p < 0.0001), independent of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (p < 0.0001 for all); and lower than expected in the general population (p < 0.001). Freedom from cardiac events was lower with an ERO ≥40 mm2 versus <40 mm2 independently of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (p < 0.0001 for all). Cardiac surgery for severe isolated TR was rarely performed (16 ± 5%) within 5 years of diagnosis.

Conclusions:

The authors concluded that isolated TR can be severe and associated with excess mortality and morbidity, suggesting heightened attention to diagnosis and quantitation. The authors advocate quantitative assessment of TR, particularly ERO measurement, as a powerful independent predictor of outcome.

Perspective:

Taken at face value, this study suggests that patients with TR in the absence of any identifiable cause, and independent of any cardiovascular or other comorbid condition, are at increased risk of death. On one level, this study is clinically provocative; on another level, it stretches the imagination. What is severe isolated TR when every primary and secondary cause of TR has been excluded—other than TR for which the cause was not identified? In the absence of data and the absence of clinical experience suggesting that intervention for ‘isolated’ TR improves outcome, it might best be considered a sign awaiting an underlying diagnosis.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pulmonary Hypertension and Venous Thromboembolism, Implantable Devices, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Pulmonary Hypertension, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound

Keywords: Defibrillators, Tricuspid Valve Insufficiency, Survival Rate, Hypertension, Pulmonary, Heart Failure, Comorbidity, Blood Pressure, Cardiac Surgical Procedures, Ventricular Dysfunction, Left, Death, Sudden, Cardiac, Echocardiography


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