Severe tricuspid regurgitation under contemporary medical therapy: a cohort analysis of the cardiorenal phenotype
L Mansour, G L'official, E DonalAbstract
Background
Severe tricuspid regurgitation (TR) is increasingly recognized as a major determinant of morbidity and mortality in heart failure, yet the natural evolution of severe TR under contemporary medical therapy and its associated cardiorenal interactions remain poorly defined.
Objectives
To analyze the longitudinal evolution of severe tricuspid regurgitation under contemporary medical therapy and to examine the integrated right ventricle-congestion-renal interactions associated with adverse outcomes over 24 months.
Methods
We conducted a retrospective observational study including 40 adult patients with echocardiographically confirmed severe TR (≥ grade 4) and clinical right-sided heart failure, managed in our teritiary center between April 2021 to March 2025. Clinical, biochemical, echocardiographic and therapeutic data were collected at baseline and at 6, 12, 18, and 24 months. Associations between treatment intensity, renal function, and clinical outcomes were examined.
Results
The cohort consisted predominantly of elderly (mean age 78.5 ± 5.5 years) and female (57.5%) patients, with severe atrial functional TR in 95% and atrial fibrillation in 93%. Patients remained highly dependent on diuretic therapy, with high-dose loop diuretics required in 57.5% at baseline and persisting over time. use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) increased from 22.5% at baseline to 89.3% at 24 months, while renin-angiotensin system inhibitors and beta-blockers declined. Under medical therapy, progressive cardiorenal deterioration was observed, with median creatinine increasing from 96.5 to 109 µmol/L and estimated glomerular filtration rate (eGFR) decreasing from 50.2 to 43.5 mL/min/1.73 m2 at 24 months. Severity adjusted high-dose of loop diuretics was independently associated with renal impairment. Significant correlations were observed between RV strain, NT-proBNP, renal function, and diuretic intensity, supporting an integrated congestion–RV–renal interaction (figure 1, 2). Clinical events (rehospitalization, intervention, or death) occurred in 50 cases across follow-up and were more frequent in patients with impaired renal function.
Conclusions
In patients with severe tricuspid regurgitation, medical therapy was associated with progressive cardiorenal deterioration and recurrent clinical events despite contemporary pharmacological management (figure 2). These findings highlight the limited ability of conservative treatment to halt disease progression and support earlier consideration of transcatheter intervention before a congestion-driven cardiorenal cycle becomes established.correlations between parameterscongestion-driven cardiorenal model