Why the study?
Severe secondary tricuspid regurgitation risk assessment remains challenging due to anatomic variability, prompting investigation into the prognostic implications of the RA/RV ratio reflecting atrial versus ventricular remodeling.
Does predominant atrial remodeling (RA/RV ratio ≥1.17) increase all-cause mortality compared to predominant ventricular remodeling (RA/RV ratio <1.17) in patients with secondary tricuspid regurgitation?
Does predominant atrial remodeling (RA/RV ratio ≥1.17) increase all-cause mortality compared to predominant ventricular remodeling (RA/RV ratio <1.17) in patients with secondary tricuspid regurgitation?
The RA/RV area ratio is a simple metric that identifies morphological substrates of secondary tricuspid regurgitation, with predominant atrial remodeling (RA/RV ≥1.17) being associated with higher long-term mortality.
May aid risk stratification of secondary TR phenotypes but should not yet change practice; leaves open whether RA/RV-guided therapy improves outcomes.
BACKGROUND: Severe secondary tricuspid regurgitation (STR) in heart failure patients is associated with excess mortality. Quantification associated risk assessment, remains challenging, specifically with contextual anatomic variability. Recent observations identified different morphological STR substrates based on predominance of ventricular or atrial remodeling, the extent of which can be expressed as right atrial/right ventricular area (RA/RV) ratio. OBJECTIVES: This study aims to investigate prognostic implications of RA/RV ratio in patients with STR. METHODS: This observational study included 13,174 STR patients, 1,219 had severe STR. Patients were allocated to predominant atrial remodeling (RA/RV ratio ≥1.17) vs predominant ventricular remodeling (RA/RV ratio <1.17). The primary endpoint was all-cause mortality. RESULTS: Both groups showed similar STR severity (effective regurgitant orifice area: 0.45 vs 0.46; P > 0.904, vena contracta: 13.7 vs 13.5; P = 0.322) and neurohumoral activation (N-terminal pro-brain natriuretic peptide 3,452 vs 3,567 P = 0.6). Long-term mortality was higher for predominant atrial remodeling than predominant ventricular remodeling (47% vs 39%, respectively). Spline analysis revealed increasing hazard with larger RA/RV ratio, and incline of hazard subsequently flattens in predominant atrial remodeling. Both STR remodeling types had impaired survival compared to patients at risk for severe STR (predominant atrial remodeling: HR: 2.1; 95% CI: 1.9-2.4; P < 0.001; predominant ventricular remodeling: HR: 1.6; 95% CI: 1.4-1.8; P < 0.001). This effect remained after multivariable adjustment. CONCLUSIONS: RA/RV ratio, an easily obtainable metric, associates with morphological features of valve apparatus distortion secondary to differential remodeling. Despite comparable quantified STR and neurohumoral activation, association between RA/RV ratio and mortality is robust. Whether RA/RV ratio might help identify patients benefiting from STR-tailored treatment, needs to be demonstrated by future research.
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Jantsch et al. (2025) studied this question.
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