Functional tricuspid regurgitation of degenerative mitral valve disease: A crucial determinant of survival

Abstract

To assess functional tricuspid regurgitation (FTR) determinants, consequences and independent impact on outcome in degenerative mitral regurgitation (DMR). All patients diagnosed with isolated DMR 2003–2011, structurally normal tricuspid leaflets, prospective FTR grading and pulmonary artery pressure (sPAP) estimation by Doppler-echocardiography at diagnosis were identified and long-term outcome analysed. The 5083 DMR eligible patients [63 ± 16 years, 47%female, ejection-fraction (EF) 63 ± 7% and sPAP 35 ± 13 mmHg] presented with FTR graded trivial in 45%, mild in 37%, moderate in 15%, and severe in 3%. While pulmonary hypertension (PHTN) was the most powerful FTR-severity determinant, other strong FTR determinants were older age, female sex, DMR, and particularly atrial fibrillation (all P ≤ 0.002). FTR moderate/severe independently linked to worse clinical presentation ( P ≤ 0.01). Survival throughout follow-up (70% at 10-year) was strongly associated with FTR-severity (82% for trivial, 69% for mild, 51% for moderate and 26% for severe, P < 0.0001). Excess-mortality persisted after comprehensive adjustment (adjusted-hazard-ratio 1.40[1.18–1.67] for moderate-FTR, 2.10[1.63–2.70] for severe-FTR, P ≤0.01), adjusting for sPAP/RV-function ( P < 0.0001), by matching (2.08[1.50–2.89], P < 0.0001) and vs. expected (1.79[1.48–2.16], P < 0.0001). Within 5-year of diagnosis surgery was performed in 73% and 15% of severe and moderate-DMR and in only 26% and 6% of severe and moderate-FTR. Valvular surgery improved outcome without alleviating higher mortality associated with FTR ( P < 0.0001). In this large DMR cohort, FTR was frequent, not only linked to PHTN, and associated with worse clinical presentation. Long-term, FTR is independently associated with considerably worse mortality while FTR moderate/severe is profoundly undertreated. Thus, careful assessment, consideration for FTR surgery and testing of new transcatheter therapy is warranted.