Prognostic value of the TRI-SCORE in concomitant surgery for secondary tricuspid regurgitation

Introduction

The TRI-SCORE was originally developed as a risk model for predicting 30-day mortality in patients undergoing isolated tricuspid valve surgery. Whether the TRI-SCORE retains prognostic value in a broader and more complex surgical population remains uncertain.

Methods

We conducted a retrospective, single-center cohort study of adults who underwent tricuspid valve repair for secondary TR performed concomitantly with other cardiac procedures between January 2018 and December 2024. The primary outcome was 5-year all-cause mortality. Secondary outcomes included 30-day mortality, 5-year heart-failure (HF) hospitalization or tricuspid reintervention, and 1-year postoperative TR severity. TRI-SCORE was calculated preoperatively for each patient.

Results

A total of 182 patients were included (mean age 65.2 ± 14.6 years; 65.4% female). Right-ventricular dysfunction was present in 19.8%, and mean TAPSE was 18.6 ± 4.1 mm. Mean LVEF was 56.2 ± 8.3% and estimated GFR 64.6 ± 26.7 mL/min. Median NYHA class was 3 (IQR 2–3), and the median daily furosemide-equivalent dose was 40 mg (IQR 20–60). Atrial fibrillation/flutter was present in 74%. Baseline TR severity was moderate in 40.0%, severe in 36.1%, and torrential in 10.0%. Concomitant procedures included mitral valve surgery (67.8%), left atrial appendage closure (34.3%), aortic valve intervention (27.1%), coronary artery bypass grafting (15.7%), and surgical AF ablation (14%). Median TRI-SCORE was 3 (IQR 1–4). Scores of 0–1 accounted for 33% of the cohort, intermediate scores of 2–4 for 44%, and high-risk scores ≥5 for 23%.

The TRI-SCORE demonstrated strong and consistent prognostic performance across all evaluated endpoints. For 30-day mortality, each 1-point increase in TRI-SCORE conferred a hazard ratio (HR) of 1.45 (95% CI 1.15–1.82; p = 0.002), with excellent discriminatory ability (AUC 0.842, 95% CI 0.753–0.931). Over long-term follow-up, the TRI-SCORE remained independently associated with 5-year all-cause mortality (HR 1.56 per point, 95% CI 1.27–1.91; p < 0.001). For the secondary composite of 5-year HF hospitalization or tricuspid reintervention, the risk also increased progressively with TRI-SCORE (HR 1.40 per point, 95% CI 1.24–1.59; p < 0.001). Furthermore, higher TRI-SCORE values predicted greater residual TR at 1 year (ρ = 0.31; p < 0.001), indicating increased TR recurrence in patients with worse baseline status.

Conclusions

In this contemporary cohort of patients undergoing concomitant surgery for secondary TR, the TRI-SCORE was strongly predictive not only of early postoperative mortality but also of long-term survival, HF-related events, and residual TR. These findings substantially extend the applicability of the TRI-SCORE beyond its original validation setting, highlighting its potential for preoperative risk stratification in non-isolated cardiac surgery involving the tricuspid valve.GraphsFor image description, please refer to the figure legend and surrounding text.