Right Heart Remodeling Redefines Risk in Significant Secondary Tricuspid Regurgitation Without Indication for Intervention

BACKGROUND: The prognostic significance of right heart remodeling (RHR) in patients with secondary tricuspid regurgitation (STR) who do not meet guideline-based indications for tricuspid valve surgery remains uncertain. We evaluated whether advanced markers of RHR are associated with outcomes in medically managed patients with significant STR. METHODS: We retrospectively included 755 patients with significant STR (age 75±12years). Patients were stratified into 3 groups: Group 1, no current surgical indication (n=519); Group 2, meeting Class I/IIa guideline criteria (n=144); and Group 3, deemed inoperable (n=92). RHR markers included right atrial volume index, right ventricular end-diastolic volume index, forward stroke volume/right ventricular end-systolic volume ratio, and effective right ventricular ejection fraction. The primary endpoint was a composite of all-cause mortality or heart failure hospitalization. RESULTS: Group 1 patients had less severe STR and less advanced right ventricular remodeling than Groups 2 and 3. Over a median follow-up of 24 months (interquartile range, 11–34), 330 primary events occurred; 64 patients underwent tricuspid valve intervention. In Group 1, 30-month event-free survival was 71±4% with no RHR markers, 65±3% with 1 or 2 markers, and 33±9% with ≥3 markers (adjusted hazard ratio [aHR], 2.76 [95% CI, 1.74–4.37]; P<0.001). Patients in Group 1 with ≥3 RHR markers had event rates comparable to Group 2 (aHR, 2.79 [95% CI, 1.94–4.02]; P<0.001) and Group 3 (aHR, 4.08 [95% CI, 2.73–6.09]; P<0.001). CONCLUSIONS: Among patients with significant STR without surgical indications, ≥3 markers of RHR identify a high-risk phenotype with outcomes similar to those meeting surgical criteria or considered inoperable.