In patients with secondary tricuspid regurgitation, predominant atrial remodeling (RA/RV ratio ≥1.17) was associated with increased 8-year mortality compared to those at risk (HR 2.00; 95% CI 1.78-2.26; p<0.001).
Observational (n=11,955)
Does predominant atrial remodeling (RA/RV ratio ≥1.17) increase all-cause mortality compared to predominant ventricular remodeling in patients with secondary tricuspid regurgitation and heart failure?
The RA/RV area ratio is a simple metric that identifies predominant remodeling patterns in secondary tricuspid regurgitation and is strongly associated with long-term mortality across all heart failure subgroups.
Hazard Ratio: 2 (95% CI 1.78–2.26)
Absolute Event Rate: 47% vs 31%
p-value: p=<0.001
Abstract Background Severe secondary tricuspid regurgitation (STR) among patients with heart failure is associated with excess mortality. Quantification associated risk assessment, remains challenging- specifically with the contextual anatomic variability. Recent observations identified different morphological substrates of STR based on the predominance of either ventricular or atrial remodeling. The extent of predominant remodeling can be expressed as ratio between right atrial/right ventricular area (RA/RV). Purpose The aim was to investigate prognostic implications of the RA/RV ratio in patients with STR and its impact across the heart failure spectrum. Methods This observational study included 11,955 patients from 2010-2020 with STR, of which 1,219 had severe STR. Based on the RA/RV ratio patients were allocated to those with predominant atrial remodeling (RA/RV ratio ≥1.17) versus those with predominant ventricular remodeling (RA/RV ratio 1.17). The primary endpoint was all-cause mortality. Results Quantified STR showed similar STR severity in both groups (EROA: 0.45 vs 0.46; p0.9, vena contracta width: 13.7 vs 13.5; p=0.3). There was no significant difference in neurohumoral activation (NT-proBNP 3,452 vs 3,567 p=0.6). At eight years, patients with predominant atrial remodeling had the highest fatal event rate compared to predominant ventricular remodeling and at risk for STR (47% vs 39% vs 31% respectively). Spline analysis revealed a linear relationship between RA/RV ratio and mortality. Both STR remodeling types had impaired survival compared to patients at risk of severe STR (predominant atrial remodeling: hazard ratio HR 2.00, 95% confidence interval CI 1.78-2.26, p0.001; predominant ventricular remodeling: HR 1.58, 95%CI 1.39-1.81 p0.001), with more prominent impact of those with RA/RV ratio ≥1.17 (p0.001). The impact of severe STR remained in both subgroups after adjustment for bootstrap and clinical confounder models. Subgroup analysis revealed excess mortality of both predominant atrial remodeling and predominant ventricular remodeling STR in patients of all heart failure subgroups. This effect was largest in patients with HF with mildly reduced ejection fraction (HFmrEF), (predominant atrial remodeling: HR 1.76, 95% CI 1.28-2.41, p0.001; predominant ventricular remodeling: HR 2.83, 95% CI 2.24-3.58 , p0.001). Conclusion RA/RV ratio is an easily obtainable metric, indicating predominant remodeling patterns and associates with morphological features of valve apparatus distortion secondary to differential remodeling. Despite comparable quantified STR and neurohumoral activation, there is a robust association between the RA/RV ratio and mortality, which persists throughout each heart failure subgroup. Whether patient selection by RA/RV ratio might help identify those that might benefit beyond symptomatic improvement needs to be demonstrated by future research.Kaplan-Meier long-term survival analysis
Jantsch et al. (Thu,) conducted a observational in Secondary tricuspid regurgitation and heart failure (n=11,955). Predominant atrial remodeling (RA/RV ratio ≥1.17) vs. Patients at risk of severe STR was evaluated on All-cause mortality (HR 2.00, 95% CI 1.78-2.26, p=<0.001). In patients with secondary tricuspid regurgitation, predominant atrial remodeling (RA/RV ratio ≥1.17) was associated with increased 8-year mortality compared to those at risk (HR 2.00; 95% CI 1.78-2.26; p<0.001).