Exercise-induced tricuspid regurgitation: clinical predictors and hemodynamic implications
C Baratto, M Mercurio, D Muraru, N Radu, M Tomaselli, G B Perego, S Paleari, M Senni, G Parati, L P Badano, S CaravitaAbstract
Background
Tricuspid regurgitation (TR) is common in cardiovascular diseases and is associated with impaired exercise capacity. Exercise could worsen TR; however, the pathophysiology and clinical relevance of exercise-induced TR (exTR) remain unclear yet.
Aim
We aimed to assess the prevalence, clinical profile, functional and hemodynamic impact of exercise-induced TR (exTR), and identify predictive factors.
Methods
One-hundred thirty-two patients (n=78 HFpEF, n=39 pulmonary vascular diseases, n=9 non-cardiac dyspnea, n=6 valvular heart disease) underwent simultaneous 3D echocardiography and right heart catheterization at rest and during low-workload exercise (20–25 Watts). TR severity was quantified using regurgitant volume (RegVol) and fraction (RegFr). ExTR was defined as an increase in TR severity by ≥1 grade during exercise. Characteristics of patients with (exTR+) and without (exTR−) exTR were compared. Multivariable logistic regression and marginal effect analyses were used to identify predictors of exTR.
Results
Thirty-four percent of patients developed exTR (figure 1). HFpEF prevalence (71 vs 53%) did not differ between ExTR+ and ExTR-. However, ExTR+ patients were older (79 [73-82] vs 69 [56-78] years), had more atrial fibrillation (AF) (67vs 17%), higher NT-proBNP levels (1374 [676-3040] vs 326 [124-824] pg/ml) and higher HFpEF-ABA probability score (93 [72-95] vs 52 [26-76]%) (p<0.001). ExTR+ exhibited greater baseline TR severity (p<0.001), larger right ventricular (RV) (p<0.05) and left atrial volumes (p=0.001), higher pulmonary and biventricular filling pressures (p<0.05), and lower cardiac output and stroke volume (p<0.05). During exercise, exTR+ displayed larger RV dilation than ExTR-(p<0.05). Right atrial pressure increased more during exercise in exTR+ (p<0.001), whereas pulmonary artery pressure increased less (p<0.05). As compared with exTR-, ExTR+ achieved lower peak oxygen consumption due to impaired cardiac output and stroke volume reserve, despite increased peripheral oxygen extraction (p<0.05). Exercise TR RegVol was directly associated with resting TR RegVol (R2=0.823) and RegFr (R2=0.729). AF (OR 4.97, 95% CI 1.12–22.01, p=0.035), baseline TR RegVol (OR 1.065, 95% CI 1.015–1.117, p=0.010) and NT-proBNP (OR 1.0004 per pg/ml, 95% CI 1.00004–1.0008, p=0.031) predicted exTR (AUC 0.91). Predicted probabilities showed that AF markedly increased the likelihood of exTR risk across increasing NT-proBNP and resting TR severity (figure 2).
Conclusions
ExTR is relatively frequent, identifies a HFpEF-like clinical–hemodynamic phenotype, and is predictable by resting TR, AF, and NT-proBNP. ExTR mirrors impaired hemodynamic adaptation to exercise, with higher right-sided filling pressure, reduced cardiac output reserve, and lower exercise capacity, highlighting its potential role for risk stratification in patients with non-severe TR.Figure 1For image description, please refer to the figure legend and surrounding text.Figure 2For image description, please refer to the figure legend and surrounding text.