Clinical Outcome of Isolated Tricuspid Regurgitation in Patients with Normal Ejection Fraction and Pulmonary Hypertension

Background:
The aim of this study was to assess the outcome of functional tricuspid regurgitation (TR) in patients with normal systolic function, no left valvar disease, and pulmonary hypertension, and the added value of semi-quantitative evaluation (vena contracta; VC) of its severity.

Methods:
In patients with functional TR, normal systolic function (EF≥ 50%), no left valvar disease, and pulmonary hypertension (systolic pulmonary pressure >50mmHg), TR was assessed both qualitatively (grade and jet area) and semi-quantitatively (VC), and long-term outcome analysis was conducted. Patients with severe co-morbid diseases, and intermediate grade of TR (mild, or mild-moderate) were excluded.

Results:
The study involved 245 patients (age 80.5 years; 37% male; ejection fraction, 57%; all with right ventricular systolic pressure >50 mm Hg). Clinically significant (≥ moderate) TR was diagnosed in 178 patients (72.6%), and their outcome compared to 67 patients with trivial TR. Four -year survival and cardiac death rate were 23% and 33% for the ≥ moderate TR group, compared with 51%, and 14% for the trivial TR group (P=0.006; P=0.055; respectively). The addition of VC width in nested models eliminated the significance of the qualitative grading and improved the model prediction (P=0.05). Significant (≥ moderate) TR was associated with lower survival, independent of all characteristics, right ventricular size or function, co-morbidity, or pulmonary pressure (p=0.03 for grade and p=0.02 for VC).

Conclusions:
TR ≥ moderate is independently associated with excess mortality in patients with normal systolic function, no left valvular disease and pulmonary hypertension, warranting heightened attention to diagnosis and grading. Semi- quantitative assessment of TR by VC is a powerful independent predictor of outcome, superior to standard qualitative assessment.