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Right Heart Failure Staging in Tricuspid Regurgitation
Quick Takes
- There is an independent association between stages of right heart failure (RHF) and survival in patients with significant secondary tricuspid regurgitation (TR).
- Standardizing the evaluation of RV dysfunction and signs and symptoms of RHF by introducing a staging system would be potentially valuable for risk stratification in clinical practice.
- Higher stages of RHF in patients with significant secondary TR may help identify patients who will benefit from earlier tricuspid surgery or new transcatheter therapies.
Study Questions:
What is the prognostic value of staging right heart failure (RHF) in patients with significant secondary tricuspid regurgitation (TR)?
Methods:
The investigators enrolled 1,311 patients with significant secondary TR (median age, 71 [interquartile range, 62-78] years; 50% male) from the departmental echocardiographic database of the Leiden University Medical Center (Leiden, the Netherlands) and divided the cohort into four RHF stages according to the presence or absence of right ventricular dysfunction (RVD) and clinical signs of RHF: Stage 1 was defined as no RVD and no signs of RHF; Stage 2 indicated RVD but no signs of RHF; Stage 3 included RVD and signs of RHF; Stage 4 was defined as RVD and refractory signs of RHF at rest. Five-year mortality rates were compared across the four stages of RHF, and the independent associates of mortality were identified by using multivariate Cox proportional hazards models.
Results:
A total of 101 patients (8%) were classified as Stage 1, 124 (10%) as Stage 2, 683 (52%) as Stage 3, and 403 (31%) as Stage 4. Patients in higher stages of RHF had more comorbidities and worse renal and left ventricular systolic function. Cumulative 5-year survival was 54%. RHF Stages 3 and 4 were independently associated with increased mortality compared to Stage 1 (hazard ratio [HR], 2.110; 95% confidence interval [CI], 1.163-3.828 and HR, 3.318; 95% CI, 1.795-6.133, respectively).
Conclusions:
The authors concluded that in patients with significant secondary TR, higher stages of RHF are independently associated with all-cause mortality at long-term follow-up.
Perspective:
This large retrospective study reports an independent association between stages of RHF and survival in patients with significant secondary TR. Based on the data that progressive stages of RHF are significantly associated with worse long-term survival, standardizing the evaluation of RV dysfunction and signs and symptoms of RHF by introducing a staging system for RHF would be potentially valuable for risk stratification in clinical practice. Additional prospective multicenter studies are indicated to validate the staging system for RHF in a broader patient population and to establish the proper timing of valvular intervention.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Cardiac Surgical Procedures, Echocardiography, Geriatrics, Heart Failure, Heart Valve Diseases, Renal Insufficiency, Risk Assessment, Secondary Prevention, Systole, Tricuspid Valve Insufficiency, Ventricular Dysfunction, Right, Ventricular Function, Left
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