Phenotype-specific trajectories of secondary tricuspid regurgitation and prognostic impact of spontaneous severity regression: a multicenter prospective cohort study
A Arteagoitia Bolumburu, J M Monteagudo Ruiz, P Mahia, E Perez David, L Gutierrez, M Sitges, P L Chi Hion, D Alonso, F Carrasco, A Adeba, J M de la Hera, J L ZamoranoAbstract
Background
Secondary tricuspid regurgitation is heterogeneous and its severity may change over time. However, the prognostic meaning of spontaneous regression across phenotypes remains uncertain.
Purpose
To characterize phenotype-specific patterns of severity change and the association between regression and cardiovascular outcomes.
Methods
Prospective multicenter cohort (9 hospitals) of consecutive adults with at least moderate secondary tricuspid regurgitation (2018) with clinical and echocardiographic follow-up through September of 2022. Primary tricuspid regurgitation and cardiac implantable electronic devices were excluded. Phenotypes were defined by prespecified echocardiographic criteria (atrial secondary, ventricular secondary, mixed). The primary endpoint was cardiovascular death or heart failure hospitalization. Regression was defined as ≥1-grade improvement in 5 grade TR scale at follow-up echocardiography.
Results
We included 1,429 patients (mean age 77 years; 65% women): ventricular secondary n=1,114 (78.5%), atrial secondary n=165 (11.6%), and mixed n=150 (10.5%). Compared with atrial secondary phenotype, ventricular secondary cases were more symptomatic and showed more right ventricle–pulmonary artery uncoupling, whereas atrial secondary cases more frequently had atrial fibrillation, larger atrial size, and higher left ventricular ejection fraction and tricuspid annular plane systolic excursion. Baseline tricuspid regurgitation severity and follow-up severity were similar between groups. From 756 patients with at least one-year follow-up TTE, regression occurred in 34.3% (atrial secondary), 40.7% (ventricular secondary), and 45.3% (mixed) (p=0.405). Spontaneous regression was associated with lower risk of cardiovascular death or heart failure hospitalizations in the overall cohort (hazard ratio 0.42; 95% confidence interval 0.2–0.7) and in the ventricular secondary phenotype (hazard ratio 0.45; 95% confidence interval 0.3–0.8), but not significantly in the atrial secondary phenotype. After multivariable adjustment for comorbidities, LVEF and VA uncoupling, regression remained independently associated with lower risk in the overall cohort (adjusted hazard ratio 0.45; 95% confidence interval 0.21–0.98).
Conclusions
In significant secondary tricuspid regurgitation, spontaneous regression occurs commonly and is independently associated with improved cardiovascular outcomes in the overall cohort and particularly in the ventricular secondary phenotype. These findings support phenotype-guided surveillance and demonstrate that severity regression identifies patients with a more favorable prognosis.TR improvement and change-patternClinical implications of TR regression