Letter by Kumar and Ahmad Regarding Article, "Prognostic Value of Complementary Echocardiography and Magnetic Resonance Imaging Quantitative Evaluation for Isolated Tricuspid Regurgitation".

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HomeCirculation: Cardiovascular ImagingVol. 15, No. 1Letter by Kumar and Ahmad Regarding Article, “Prognostic Value of Complementary Echocardiography and Magnetic Resonance Imaging Quantitative Evaluation for Isolated Tricuspid Regurgitation” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBLetter by Kumar and Ahmad Regarding Article, “Prognostic Value of Complementary Echocardiography and Magnetic Resonance Imaging Quantitative Evaluation for Isolated Tricuspid Regurgitation” Arushi Kumar, iBsc and Mahmood Ahmad, MBBS Arushi KumarArushi Kumar https://orcid.org/0000-0002-8127-6337 University College London Hospitals, United Kingdom (A.K.). Search for more papers by this author and Mahmood AhmadMahmood Ahmad Royal Free Hospital, London, United Kingdom (M.A.). Search for more papers by this author Originally published24 Dec 2021https://doi.org/10.1161/CIRCIMAGING.121.013754Circulation: Cardiovascular Imaging. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 24, 2021: Ahead of Print To the Editor:We read with interest the article by Wang et al1 which investigated the prognostic value and thresholds of cardiac magnetic resonance (CMR)-derived markers for isolated tricuspid regurgitation (TR). CMR-derived TR fraction (TRF) and right ventricle free wall longitudinal strain measured by echocardiography was found to be independently associated with worse survival and heart failure symptoms. This study shows the clinically relevant association of TR severity and clinical outcomes which included heart failure symptoms.Zhan et al2 were among the first to determine the prognostic value of CMR-derived markers such as TRF and TR volume) in functional TR and found a threshold of TR volume ≥45 mL and TRF of ≥50% was associated with the highest risk of all-cause mortality. Both quantify volume regurgitated but TRF adjusts for systemic circulation which may provide a greater prognostic implication when comparing patients with different flow states. TR severity can vary with preload so renal disease and heart failure in an increasingly co-morbid patient population may be better reflected using TRF. We suggest that these markers could be compared with Wang et al and their data.Hinojar et al3 studied CMR-derived early markers of right ventricular (RV) dysfunction in severe TR. Effective RV ejection fraction ≥34% and RV shortening of ≥14% were associated with better prognosis for a combined endpoint of hospital admission for right heart failure and cardiac mortality. Effective RV ejection fraction was an independent predictor of outcome and showed earlier dysfunction than RV ejection fraction. These markers are less dependent on preload-a factor which may appear unaffected until late in the disease due to compensatory increased contraction. Both parameters had stronger association with RV dysfunction compared to RV ejection fraction, with effective RV ejection fraction having the strongest association. They were both strongly associated with TR severity and Wang et al1 could correlate this with their dataCMR-derived RV free wall longitudinal strain, a measure of longitudinal RV function was found to be an independent predictor of mortality in severe functional TR by Romano et al.4 They theorize the subendocardial longitudinal fibers are affected in RV long-axis function as detected by RV free wall longitudinal strain. It was incrementally more prognostic compared to clinical and CMR variables.Kresoja et al5 found CMR-derived global RV dysfunction was a significant predictor of a composite outcome of all-cause mortality or first heart failure hospitalization in patients with significant TR undergoing transcatheter tricuspid valve repair. The team found deterioration of longitudinal function can be compensated for by increased circumferential strain, allowing RV function preservation and more favorable outcomes. Clinicians may be able to use these findings for CMR to detect dysfunction which may be missed by assessment of RV function alone.The prognostic value of CMR for TR has been well established but there is a lack of clarity on early markers of dysfunction and prognosis, to optimize treatment timing. Wang et al1 and Hinojar et al3 have determined thresholds for different CMR markers, and we would suggest further data be gathered to clarify which markers are most prognostically useful.Disclosures None.FootnotesFor Disclosures, see page 81.