Gender differences in clinical phenotype, right-heart remodelling and outcomes in severe tricuspid regurgitation: a cardiac magnetic resonance study

Aims Severe tricuspid regurgitation (TR) is more prevalent in women; however, whether sex influences clinical outcomes remains unclear. This study investigated sex-related differences in clinical presentation, right ventricular (RV) remodelling assessed by cardiac magnetic resonance (CMR), and all-cause mortality in patients with severe TR. Methods and results Patients with at least severe TR assessed by echocardiography who subsequently underwent CMR were enrolled from five tertiary hospitals. The primary outcome was all-cause mortality under medical therapy. Patients undergoing tricuspid valve intervention were censored at the time of the procedure. Patients were followed for up to 10 years (median 35 months; interquartile range (IQR) 12–60). A total of 326 patients (mean age 71 ± 11 years; 67% women) were included. Women had a lower prevalence of diabetes, coronary artery disease, and chronic kidney disease (all P < 0.05). Atrial functional TR was more prevalent in women, whereas ventricular TR predominated in men (P < 0.05). On CMR, women demonstrated lower indexed RV and right atrial volumes and higher right ventricular ejection fraction (P < 0.01). Rates of tricuspid valve intervention were similar between groups (28% vs. 29%, P = 0.53). Women showed better 10-year survival than men (53% vs. 25%, P < 0.001). Male sex remained independently associated with all-cause mortality in multivariable analysis after inverse probability of treatment weighting [hazard ratio (HR) 2.08 (1.30–3.33), P = 0.002] and after propensity score matching [HR 1.81 (1.04–3.15), P = 0.036]. Conclusion Women with severe TR exhibited fewer comorbidities, predominantly atrial TR, less RV remodelling, and better long-term survival compared with men. Sex-specific phenotyping may improve risk stratification and support more individualized therapeutic strategies.