Author + information
- Received July 3, 2018
- Revision received October 19, 2018
- Accepted November 7, 2018
- Published online March 4, 2019.
- Philipp E. Bartko, MD, PhDa,
- Henrike Arfsten, MDa,
- Maria K. Frey, MD, PhDa,
- Gregor Heitzingera,
- Noemi Pavo, MD, PhDa,
- Anna Choa,
- Stephanie Neuhold, MDb,
- Timothy C. Tan, MBBS, PhDc,d,
- Guido Strunk, PhDe,
- Christian Hengstenberg, MDa,
- Martin Hülsmann, MDa and
- Georg Goliasch, MD, PhDa,∗ ()
- aDepartment of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- bDepartment of Medicine IV, Kaiser-Franz-Joseph-Spital, Vienna, Austria
- cWestmead Hospital, Faculty of Medicine, University of Sydney, Sydney, Australia
- dDepartment of Cardiology, Blacktown Hospital, Blacktown, Australia
- eFH Campus Vienna and Complexity Research, Vienna, Austria
- ↵∗Address for correspondence:
Dr. Georg Goliasch, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
Objectives This study sought to define the relationship between functional tricuspid regurgitation (TR) and mortality in patients with heart failure with reduced ejection fraction (HFrEF); and to establish the prognostic value of quantitative measures of TR severity (i.e., effective regurgitant orifice area [EROA] and regurgitant volume).
Background The significance of TR in chronic heart failure is controversial. Earlier studies have shown an independent impact of TR on mortality, whereas more recent evidence suggests myocardial impairment to be the driving force of mortality rather than TR itself. Earlier studies have used qualitative measures of TR severity, hence the prognostic value of more quantitative measures of TR severity (i.e., EROA and regurgitant volumes) remains unclear.
Methods We enrolled 382 patients with HFrEF on guideline-directed medical therapy and assessed TR EROA and regurgitant volume by Doppler/2-dimensional echocardiography. All-cause mortality was defined as the primary study endpoint.
Results TR severity was associated with the HFrEF phenotype with more symptoms (p = 0.004), higher neurohumoral activation (p < 0.001), progressive right-ventricular dilatation (p < 0.001), and impaired function (p < 0.001). Cox regression showed a strong association between quantitative measures of TR with mortality (all p < 0.001). Quantitative metrics of TR severity were consistently associated with mortality with a hazard ratio of 1.009 (95% confidence interval: 1.004 to 1.013; p < 0.001) per 0.01 cm2 increase of the EROA and of 1.013 (95% confidence interval: 1.007 to 1.020; p < 0.001) per 1-ml increase in regurgitant volume. Results remained unchanged after bootstrap- or clinical confounder-based adjustment. A spline curve pattern illustrates the association with mortality with thresholds for the EROA ≥0.2 cm2, and the regurgitant volume ≥20 ml with sustained excess mortality thereafter.
Conclusions This large-scale outcome study demonstrates the prognostic value of quantitative Doppler-echocardiographic measures of TR severity in HFrEF. The thresholds for EROA and TR regurgitant volume associated with mortality in our study fall within current ranges defining nonsevere TR. This may potentially impact therapeutic decision making, particularly timing of intervention.
- effective regurgitant orifice area
- heart failure with reduced ejection fraction
- regurgitant volume
- tricuspid regurgitation
- vena contracta width
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 3, 2018.
- Revision received October 19, 2018.
- Accepted November 7, 2018.
- 2019 American College of Cardiology Foundation
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