Hemodynamic phenotypes and clinical outcomes in patients with severe tricuspid regurgitation

Introduction - Tricuspid regurgitation (TR), once regarded as a relatively benign finding, is now recognized as a condition with major prognostic implications. Beyond clinically evident venous congestion, TR can result in reduced forward cardiac flow. Severity conventional assessment focuses largely on regurgitation quantification. Stroke volume (SV) is an integrated marker of right sided cardiac performance that has not been adequately evaluated in the assessment of severe TR. Methods -We retrospectively analyzed consecutive patients with significant TR (>moderate) undergoing echocardiography assessment at a large tertiary referral center. SV was calculated using LVOT Doppler and area, and RAP was determined using inferior vena cava assessment. Patients were stratified into four hemodynamic phenotypes: (1) Normal (normal SV, normal RAP), (2) Forward failure (low SV, normal RAP), (3) Congested (normal SV, high RAP), and (4) Combined (low SV, high RAP). This cohort was followed for the primary outcome of mortality. Results -Among 1,543 patients (median age 79 years, 50% female), 35% were classified as "Normal", 16% as "Forward failure", 21% as "Congested", and 29% as "Combined". Over a median follow-up of 4.2 years, all non-Normal phenotypes exhibited significantly higher mortality risk, with the Combined group with the greatest risk (adjusted HR 1.62, 95% CI 1.36–1.91, p<0.001). Traditional right ventricle function markers (TAPSE, s′) did not independently predict survival. Advanced multivariate analysis performed on patients without any other significant valvular disease revealed that only the combined group had higher hazard for mortality (HR 1.42, 95% CI 1.05-1.92, p=0.023). Conclusion -In severe TR, classification by SV and RAP identifies different hemodynamic phenotypes with marked prognostic significance. Reduced SV, especially when coupled with congestion, can be independently associated with excess mortality. Incorporating forward flow into echocardiographic evaluation may refine risk stratification and guide timely intervention.