Proportionality of tricuspid regurgitation determines outcome in acute heart failure

Abstract

Abstract Introduction The impact of tricuspid regurgitation (TR) on outcomes in acute heart failure (AHF) incompletely understood. Often TR is considered secondary to right ventricular (RV) remodelling and dysfunction, and it is not clear if the regurgitant volume itself has additional adverse effects on outcome. We hypothesised a novel index, where TR regurgitant volumes (TRRV [ml]) are divided by the RV end-diastolic volumes (RVEDV [ml]) may help to identify patients at risk of poor outcome. Purpose To identify a cut-off for disproportionate TR and to assess its impact on survival in AHF. Methods 418 consecutive patients admitted with AHF over 12 months to a single centre in the United Kingdom were recruited and followed up for 2 years. The endpoint was death from any cause. TR RV was calculated using the proximal isovelocity surface area method and right ventricular volumes using ellipsoid model. Receiver Operator Curve analyses were carried for the TRRV/RVEDV index. The optimum cut-off for prediction of 2-year mortality was estimated by identifying the sensitivity and specificity associated with the maximum Youden Index. These cut-offs were then used as a binary determinant of proportionate vs disproportionate TR. Results 357/418 patients displayed TR (85.4%). The maximum Younden index associated criterion was >44.3, which defined a binary determinant of disproportionate TR. There were no significant differences in baseline characteristics however patients with disproportionate TR were slightly older, predominantly female with chronic kidney disease, but a lower prevalence of diabetes. The mechanism of disproportionality in TR appears to be driven by increasing regurgitant volumes (79.2±47.2ml vs 22.9±19.5ml) and pulmonary artery pressures (50.7±16.4mmHg vs. 63.1±20.0mmHg) as RVEDV were similar between groups (113.5±48.8ml vs. 107.0±45.8ml). Patients with disproportionate TR were at greater risk of 2-year mortality (47.2%) compared to proportionate TR (36.6%) (HR 1.50; CI 1.03–2.15 [p=0.034]). Conclusion The disproportionate TR cut-off of 44.3ml-2 was able separate out those at greater risk. RVFAC, a traditional measurement of RV function was very similar between the two groups. This suggests rapid echo assessment may help to risk stratify patients presenting in AHF, aiding clinical decision making. Funding Acknowledgement Type of funding sources: None. Kaplan-Meier survival curveBaseline characteristics