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Morphological and functional types of tricuspid regurgitation: prognostic value in patients undergoing tricuspid annuloplasty during left-sided valvular surgery

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Abstract

Background

The nonuniform benefit of tricuspid annuloplasty may be explained by the proportionality of tricuspid regurgitation (TR) severity to right ventricular (RV) area. The purpose of this study was to delineate distinct morphological phenotypes of functional TR and investigate their prognostic implications in patients undergoing tricuspid annuloplasty during left-sided valvular surgery.

Methods

The ratios of pre-procedural effective regurgitant orifice area (EROA) with right ventricular end-diastolic area (RVDA) were retrospectively assessed in 290 patients undergoing tricuspid annuloplasty. Based on optimal thresholds derived from penalized splines and maximally selected rank statistics, patients were stratified into proportionate (EROA/RVDA ratio ≤ 1.74) and disproportionate TR (EROA/RVDA ratio > 1.74).

Results

Overall, 59 (20%) and 231 (80%) patients had proportionate and disproportionate TR, respectively. Compared to those with proportionate TR, patients with disproportionate TR were older, had a higher prevalence of atrial fibrillation, lower pulmonary pressures, more impaired RV function, and larger tricuspid leaflet tenting area. Over a median follow-up of 4.1 years, 79 adverse events (47 heart failure hospitalizations and 32 deaths) occurred. Patients with disproportionate TR had higher rates of adverse events than those with proportionate TR (32% vs 10%; P = 0.001) and were independently associated with poor outcomes on multivariate analysis. TR proportionality outperformed guideline-based classification of TR severity in outcome prediction and provided incremental prognostic value to both the EuroSCORE II and STS score (incremental χ2 = 6.757 and 9.094 respectively; both P < 0.05).

Conclusions

Disproportionate TR is strongly associated with adverse prognosis and may aid patient selection and risk stratification for tricuspid annuloplasty with left-sided valvular surgery.

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Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Funding

This work was supported by the Sanming Project of Medicine in Shenzhen, China (No. SZSM201911020) and HKU-SZH Fund for Shenzhen Key Medical Discipline (No. SZXK2020081).

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Authors and Affiliations

  1. Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China

    Yi-Kei Tse, Hang-Long Li, Qing-Wen Ren, Jia-Yi Huang, Mei-Zhen Wu, Calvin Ka-Lam Leung, Si-Yeung Yu, Denise Hung, Hung-Fat Tse & Kai-Hang Yiu

  2. Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China

    Yi-Kei Tse, Hang-Long Li, Qing-Wen Ren, Jia-Yi Huang, Mei-Zhen Wu, Calvin Ka-Lam Leung, Si-Yeung Yu, Denise Hung, Hung-Fat Tse & Kai-Hang Yiu

  3. Department of Medical Sciences, Cardiology and Clinical Physiology, Uppsala University and Uppsala University Hospital, Uppsala, Sweden

    Frank A. Flachskampf

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  1. Yi-Kei Tse
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Contributions

Conceptualization: Y-KT, FAF, K-HY; methodology: Y-KT, H-LL, Q-WR, J-YH, M-ZW, CK-LL, S-YY, DH, H-FT, FAF, K-HY; formal analysis and investigation: Y-KT; writing—original draft preparation: Y-KT, FAF, K-HY; writing—review and editing: Y-KT, H-LL, FAF, K-HY; funding acquisition: K-HY; supervision: H-FT, FAF, K-HY.

Corresponding author

Correspondence to Kai-Hang Yiu.

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The authors have no competing interests to declare that are relevant to the content of this article.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the ethics committee of the West Cluster Hospital Authority of Hong Kong (UW 13–169).

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Tse, YK., Li, HL., Ren, QW. et al. Morphological and functional types of tricuspid regurgitation: prognostic value in patients undergoing tricuspid annuloplasty during left-sided valvular surgery. Clin Res Cardiol 112, 1463–1474 (2023). https://doi.org/10.1007/s00392-023-02265-6

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