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±12 years). 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 end point 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.