Prevalence, predictors, and hemodynamic impact of exercise-induced tricuspid regurgitation
C Baratto, M Mercurio, C Lopiano, S Vani, D Muraru, G B Perego, S Paleari, M Senni, G Parati, L P Badano, S CaravitaAbstract
Background
Exercise could worsen tricuspid regurgitation (TR). However, the pathophysiology and clinical relevance of exercise-induced TR (exTR) remain unclear yet.
Aims
We sought to evaluate the occurrence of exTR, its impact on exercise pathophysiology, and identify predictive factors.
Methods
Consecutive patients undergoing simultaneous three-dimensional echocardiography and right heart catheterization at rest and during exercise were classified as exercise-induced TR (exTR+) if TR severity increased by ≥1 grade during exercise. Clinical characteristics were compared between exTR+ and exTR-, and logistic regression and marginal effect analyses were used to identify predictors of exTR.
Results
ExTR occurred in 34% of 132 patients (figure 1). ExTR+ patients were older(79 [73-82] vs 69 [56-78] years), more frequently had atrial fibrillation (AF) (67 vs 17%), higher NTproBNP (1374 [676-3040] vs 326 [124-824] pg/ml), larger left atrium (p=0.001), and higher heart failure with preserved ejection fraction (HFpEF) probability scores (93 [72-95] vs 52 [26-76]%) (p<0.001), (p<0.001). ExTR+ exhibited greater baseline tricuspid regurgitation (TR) severity (p<0.001), larger right ventricle (RV) (p<0.05) and worse resting hemodynamics. ExTR+, as compared with exTR-, displayed worse maladaptive exercise responses, including dynamic RV dilation (p<0.001), marked right atrial pressure (RAP) rise (20±8 vs 13±6 mmHg, p<0.001), lower cardiac output (CO) (6.17 [4.99 ;7.81] vs 8.04 [6.08 ;10.45] L/min, p<0.001) and exercise capacity (p<0.05). Baseline TR (OR 1.065, 95% CI 1.015–1.117, p=0.010), AF (OR 4.97, 95% CI 1.12–22.01, p=0.035), and NTproBNP (OR 1.0004 per pg/ml, 95% CI 1.00004–1.0008, p=0.031) independently predicted exTR, with excellent model discrimination (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 may frequently occur in patients with HFpEF-like clinical–hemodynamic phenotype. ExTR is associated with a maladaptive exercise response, highlighting its potential role for risk stratification in patients with borderline TR. Its occurrence is predictable by combining resting TR severity, AF, and NT-proBNP.figure 1figure 2