Elsevier

JACC: Cardiovascular Imaging

Volume 7, Issue 12, December 2014, Pages 1185-1194
JACC: Cardiovascular Imaging

Original Research
Clinical Outcome of Isolated Tricuspid Regurgitation

https://doi.org/10.1016/j.jcmg.2014.07.018Get rights and content
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Abstract

Objectives

The aim of this study was to assess the outcome of isolated tricuspid regurgitation (TR) and the added value of quantitative evaluation of its severity.

Background

TR is of uncertain clinical outcome due to confounding comorbidities. Isolated TR (without significant comorbidities, structural valve disease, significant pulmonary artery systolic pressure elevation by Doppler, or overt cardiac cause) is of unknown clinical outcome.

Methods

In patients with isolated TR assessed both qualitatively and quantitatively by a proximal isovelocity surface area method, a long-term outcome analysis was conducted. Patients with severe comorbid diseases were excluded.

Results

The study involved 353 patients with isolated TR (age 70 years; 33% male; ejection fraction, 63%; all with right ventricular systolic pressure <50 mm Hg). Severe isolated TR was diagnosed in 76 patients (21.5%) qualitatively and 68 patients (19.3%) by quantitative criteria (effective regurgitant orifice [ERO] ≥40 mm2). The 10-year survival and cardiac event rates were 63 ± 5% and 29 ± 5%. Severe isolated TR independently predicted higher mortality (adjusted hazard ratio: 1.78 [95% confidence interval (CI): 1.10 to 2.82], p = 0.02 for qualitative definition and 2.67 [95% CI: 1.66 to 4.23] for an ERO ≥40 mm2, p < 0.0001). The addition of grading by quantitative criteria in nested models eliminated the significance of the qualitative grading and improved the model prediction (p < 0.001 for survival and p = 0.02 for cardiac events). The 10-year survival rate was lower with an ERO ≥40 mm2 versus <40 mm2 (38 ± 7% vs. 70 ± 6%; p < 0.0001), independent of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (p < 0.0001 for all), and lower than expected in the general population (p < 0.001). Freedom from cardiac events was lower with an ERO ≥40 mm2 versus <40 mm2 independently of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (p < 0.0001 for all). Cardiac surgery for severe isolated TR was rarely performed (16 ± 5% 5 years after diagnosis).

Conclusions

Isolated TR can be severe and is associated with excess mortality and morbidity, warranting heightened attention to diagnosis and quantitation. Quantitative assessment of TR, particularly ERO measurement, is a powerful independent predictor of outcome, superior to standard qualitative assessment.

Key Words

effective regurgitant orifice
isolated tricuspid regurgitation
prognosis
tricuspid regurgitation

Abbreviations and Acronyms

ERO
effective regurgitant orifice
RV
right ventricular
SPAP
systolic pulmonary artery pressure
TR
tricuspid regurgitation

Cited by (0)

Dr. Suri is a national principal investigator for the Sorin-Perceval Trial 2; is the co-principal investigator for the Abbott COAPT trial 3 and COAPT trial; is a Clinical Steering Committee of the St. Jude Medical Portico Trial; has patent applications with Sorin Perceval Trial and Sorin; and has received research support from Sorin, Abbott, St. Jude Medical, and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.