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TRI-SCORE and Benefit of Intervention in Severe Tricuspid Regurgitation
Quick Takes
- Using retrospectively collected data from the TRIGISTRY multicenter, multinational registry, the 2-year survival of adult patients with severe functional tricuspid regurgitation (TR) was lower among patients with progressively higher TRI-SCORE.
- Among patients with severe functional TR, 2-year survival was better after surgical or transcatheter repair compared to conservatively managed patients only among those at low risk based on TRI-SCORE or intermediate TRI-SCORE risk and successful repair, with no survival advantage associated with intervention among patients with high TRI-SCORE risk.
Study Questions:
What are survival rates after surgical or transcatheter intervention compared to conservative management based on tricuspid regurgitation (TR) clinical stage assessed using TRI-SCORE?
Methods:
Data from TRIGISTRY (a registry that retrospectively collected data on adult patients with severe isolated functional TR seen at 1 of 33 centers in 10 countries) were used to identify 2,413 patients with severe isolated functional TR; including 1,217 who were conservatively managed, 551 who underwent isolated tricuspid valve surgery, and 645 who underwent isolated transcatheter tricuspid valve repair. For the calculation of TRI-SCORE, dosages of torsemide and bumetanide were converted to equivalent doses of furosemide. Successful correction of TR was defined as ≤ mild to moderate (≤2+) TR. Clinical outcome was assessed based on TRI-SCORE and conservative or interventional management, with a primary study endpoint of survival at 2 years.
Results:
The TRI-SCORE predicted low risk (TRI-SCORE ≤3) in 32% of patients, intermediate risk (TRI-SCORE 4-5) in 33%, and high risk (TRI-SCORE ≥6) in 35%. Follow-up was available in 98% of patients (median 1.7 years [interquartile range 0.46-2 years]). Successful correction of TR was achieved in 97% of patients who underwent surgery and 65% of patients who underwent transcatheter repair. The 2-year survival rates decreased with increasing TRI-SCORE risk category overall (2-year survival 83% in low-risk, 74% in intermediate-risk, and 59% in high-risk patients; p < 0.0001) and in each of the three treatment groups (all p < 0.001).
In the TRI-SCORE low-risk category, survival rates were higher in the surgical and transcatheter groups than in the conservative management group (2-year survival 93%, 87%, and 79%, respectively; p = 0.0002). In the TRI-SCORE intermediate-risk category, no significant difference between groups was observed overall (survival rates 80%, 71%, and 71%, respectively; p = 0.13); however, a significant benefit associated with intervention was observed when analysis was restricted to patients with successful correction of TR (survival rates 80%, 81%, and 71%, respectively; p = 0.009). In the TRI-SCORE high-risk category, 2-year survival was not different between the surgical and successful repair groups versus the conservatively managed group (61% and 68% vs. 58%, p = 0.26 and p = 0.18, respectively).
Conclusions:
Survival progressively decreased with higher TRI-SCORE risk categories irrespective of treatment modality. Compared to conservative management, early and successful surgical or transcatheter intervention was associated with improved 2-year survival in patients with low and (to a lesser degree) intermediate risk TRI-SCORE, whereas intervention was not associated with benefit in patients with a high-risk TRI-SCORE.
Perspective:
The tricuspid valve is no longer ‘the forgotten valve’; there is increasing recognition of TR as a common cause of symptoms and right-sided heart failure, and increasing interest in surgical and transcatheter interventions with or without concomitant cardiac intervention in patients with severe TR. The TRI-SCORE score, based on eight clinical and echocardiographic factors (age, New York Heart Association functional class, right-sided heart failure signs, daily dose of furosemide, glomerular filtration rate, total bilirubin, left ventricular ejection fraction, and right ventricular function), has been used to help predict in-hospital mortality after isolated tricuspid valve surgery. In this study, it was found to be associated with 2-year survival among adult patients with severe functional TR who were conservatively managed and among those who underwent either surgical or transcatheter tricuspid repair.
Unlike in the TRILUMINATE study (Sorajja P, et al., N Engl J Med 2023;388:1833-42), surgical and transcatheter repair in this study were associated with improved 2-year survival compared to conservatively managed patients, but only in the settings of a low-risk TRI-SCORE or intermediate-risk TRI-SCORE and successful intervention. The implications are that surgical or transcatheter repair of severe functional TR might be most effective during earlier rather than later stages of disease progression.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Interventions and Structural Heart Disease, Cardiac Surgery and Heart Failure, Valvular Heart Disease
Keywords: Cardiac Surgical Procedures, Tricuspid Valve Insufficiency
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