Frequency and Associated Clinical Features of Functional Tricuspid Regurgitation in Patients With Chronic Atrial Fibrillation

Incremental value of tricuspid annular enlargement to progressive tricuspid regurgitation in patients with longstanding persistent atrial fibrillation

Tricuspid annular enlargement in patients with atrial fibrillation (AF) can induce tricuspid regurgitation (TR). However, risk factors associated with TR progression in patients with AF have not been defined. This study aimed to clarify an association between tricuspid annular diameter (TAD) and TR progression in patients with longstanding persistent AF. We retrospectively analyzed data from 228 patients who had longstanding persistent AF for > 1 year and mild or less TR on baseline echocardiograms. We defined significant TR as moderate or greater TR, graded according to the jet area and vena contracta. The optimal cut-off value of the TAD index (TADI), based on body surface area for predicting progression to significant TR, was estimated using receiver operating characteristic (ROC) curves. The independence and incremental value of the TADI were evaluated using multivariate Cox proportional hazard regression analysis and likelihood ratio tests. Over a median follow-up of 3.7 years, 55 (24.1%) patients developed significant TR. The optimal cut-off value of 21.1 mm/m2 for the TADI at baseline and ROC curves predicted TR progression with 70.4% sensitivity and 86% specificity. Furthermore, TADI was an independent predictor of TR progression (hazard ratio, 1.32; 95% confidence interval, 1.17-1.49, P < 0.001) and had a significant incremental value that exceeded that of models constructed using clinical parameters. In conclusion, TADI was significantly associated with TR progression and was an independent predictor of TR progression in longstanding persistent AF.

Predictors of Progression of Tricuspid Regurgitation in Patients with Persistent Atrial Fibrillation

Previous studies have shown that tricuspid regurgitation (TR) can be developed in patients with atrial fibrillation (AF) due to annular dilatation. This study aimed to investigate the incidence and predictors of the progression of TR in patients with persistent AF. A total of 397 patients (66.9±11.4 years, 247 men; 62.2%) with persistent AF were enrolled between 2006 and 2016 in a tertiary hospital, and 287 eligible patients with follow-up echocardiography were analyzed. They were divided into two groups according to TR progression (progression group [n=68, 70.1±10.7 years, 48.5% men] vs. non-progression group [n=219, 66.0±11.3 years, 64.8% men]). Among 287 patients in the analysis, 68 had worsening TR severity (23.7%). Patients in the TR progression group were older and more likely to be female. Patients with left ventricular ejection fraction <50% were less frequent in the progression group than those in the non-progression group (7.4% vs. 19.6%, p=0.018). Patients with mitral valve disease were more frequent in the progression group. Multivariate analysis with COX regression demonstrated independent predictors of TR progression, including left atrial (LA) diameter >54 mm (HR 4.85, 95%CI 2.23-10.57, p<0.001), E/e' (HR 1.05, 95%CI 1.01-1.10, p=0.027), and no use of antiarrhythmic agents (HR 2.20, 95%CI 1.03-4.72, p=0.041). In patients with persistent AF, worsening TR was not uncommon. The independent predictors of TR progression turned out to be greater LA diameter, higher E/e', and no use of antiarrhythmic agents.

Incidence of atrial functional tricuspid regurgitation and its correlation with tricuspid valvular deformation in patients with persistent atrial fibrillation

Background

With the growing prevalence of atrial fibrillation (AF), concomitant atrial functional tricuspid regurgitation (FTR) is increasing. In this study, we aimed to elucidate the incidence of significant atrial FTR and its association with tricuspid valvular (TV) deformation in patients with persistent AF.

Methods

We retrospectively enrolled 344 patients (73.0 ± 9.3 years, 95 female) with persistent AF who underwent 2-dimensional echocardiography. We excluded patients with left-sided heart disease, pulmonary hypertension treated with pulmonary vasodilators, and congenital heart disease. We defined significant TR as having TR ≥ moderate; and tricuspid annulus (TA) diameter, tethering height, and area were measured in all patients.

Results

Among the study population, 80 (23.3%) patients had significant TR. TA diameter, tethering height, and area were significantly greater in the significant TR group (all p < 0.001). In multivariable analysis, TA diameter was independently associated with significant TR (odds ratio 1.1 per mm, p = 0.03), whereas TV tethering height was not. Receiver operating characteristic curve for significant TR exhibited the best predictive value of TA diameter indexed for body surface area [23 mm/m²; area under the curve (AUC) = 0.87] compared with absolute TA diameter (39 mm; AUC = 0.74) and TA diameter indexed for height (0.22 mm/cm; AUC = 0.80).

Conclusion

Approximately 25% of patients with persistent AF had significant TR. The BSA-corrected TA diameter was strongly associated with significant TR, which might be helpful for predicting the development of significant TR and considering its therapeutic strategy in patients with persistent AF.

Association of longitudinal left atrial strain with mortality after tricuspid valve surgery

AIMS

Tricuspid valve (TV) surgery for functional tricuspid regurgitation (TR) is becoming more common, but the associated mortality remains high. Therefore, we evaluated the clinical and echocardiographic parameters associated with all-cause mortality in patients with severe functional TR who underwent TV surgery.

METHODS AND RESULTS

A total of 286 patients with severe functional TR who underwent TV replacement or repair was analysed between January 2006 and December 2017. We assessed changes in conventional echocardiographic parameters and strain, such as peak atrial longitudinal strain (PALS). During a median follow-up period of 5.3 years, 71 (24.8%) patients died due to any cause. When comparing groups with and without all-cause deaths, there were no significant differences in terms of sex, co-morbidities, medication use, and surgery type. However, patients who died were older and more likely to have refractory atrial fibrillation (AF). With multivariate Cox modelling, age >65 years (adjusted hazard ratio [HR], 2.81, 95% confidence interval [CI], 1.59-4.96; P < 0.001), refractory AF (adjusted HR, 2.84, 95% CI, 1.36-5.94; P = 0.006), lower albumin level (adjusted HR, 0.50, 95% CI, 0.31-0.82), and reduced PALS (adjusted HR, 1.87, 95% CI, 1.06-3.33; P = 0.032) were significant determinants of all-cause mortality. PALS decline was associated with refractory AF (adjusted HR, 5.74, 95% CI, 2.81-11.7; P < 0.001) and the absence of a Maze procedure (adjusted HR, 2.95, 95% CI, 1.51-5.78; P = 0.002).

CONCLUSIONS

A reduction in PALS was significantly associated with all-cause mortality in our cohort of patients with severe functional TR who underwent TV surgery. This phenomenon is related to refractory AF and more aggressive intervention for AF is necessary concomitant with TV surgery.

Atrial Mitral and Tricuspid Regurgitation: Sex Matters. A Call for Action to Unravel the Differences Between Women and Men

Atrial functional regurgitation is caused by atrioventricular annulus dilation, with normal leaflets and ventricular dimensions and function within the normal range. Its occurrence, in both mitral and tricuspid valves, implies a worse prognosis due to the hemodynamic derangement they produce, but also constitutes a marker of greater comorbidity and more advanced disease. Predisposing conditions for these heart valve dysfunctions are mainly atrial fibrillation and heart failure with preserved ejection fraction. However, other factors like female sex also may be involved and influence their incidence, especially for atrial tricuspid regurgitation. In the present review, we analyze sex differences in the reported prevalence of atrial mitral and tricuspid regurgitation, and suggest possible mechanisms involved. Finally, we underline potential therapeutic and preventive strategies to reduce the burden of these heart valve disorders and discuss research gaps.

Prevalence and factors associated with atrial mitral and tricuspid regurgitation in patients with atrial fibrillation

BACKGROUND

This study aimed to examine the prevalence of atrial tricuspid regurgitation (ATR) and atrial mitral regurgitation (AMR) in the setting of atrial fibrillation (AFib) and identify variables related to the severity of both types of regurgitation.

METHODS

Cross-sectional study evaluating data from transthoracic echocardiograms performed during 2019. We included patients with AFib during the examination, and without primary valve disease or other significant heart disease.

RESULTS

Four-hundred and thirty-two patients fulfilled the inclusion criteria (mean age 77.5±9.2 years, 49.1% women). We observed significant ATR in 14.8%, and significant AMR in 1.4% of patients. ATR and AMR severities were equal in 49.3% of patients, and 41% displayed greater ATR severity. ATR prevalence was significantly greater among women (23.1% vs 6.8%, p < 0.001), but AMR prevalence was similar between genders (1.9% vs .9%, p = 0.443). Variables related to greater ATR severity were: female sex (OR: 2.61, 95%CI: 1.60-4.24), left atrial (LA) volume (OR: 3.58, 95%CI: 1.50-8.55), systolic pulmonary artery pressure (OR: 1.10, 95%CI: 1.07-1.13), and moderate AMR (OR: 2.21, 95%CI: 1.22-4.00). Variables related to greater AMR severity were female sex (OR: 1.96, 95%CI: 1.24-3.09), LA volume (OR: 11.68, 95%CI: 5.29-25.80), and body mass index (OR: .94, 95%CI: .90-.98).

CONCLUSIONS

In the context of AFib, ATR was more prevalent than AMR and prevailed in women. LA enlargement was associated with higher degrees of both AMR and ATR. Pulmonary hypertension was also independently associated with ATR, as well as greater AMR severity, suggesting possible adaptive changes in leaflets that might modify the atrial regurgitation incidence.

The Pathophysiological Link between Right Atrial Remodeling and Functional Tricuspid Regurgitation in Patients with Atrial Fibrillation: A Three-Dimensional Echocardiography Study

BACKGROUND

Atrial fibrillation (AF) itself may lead to functional tricuspid regurgitation (FTR) through tricuspid annulus (TA) dilation. However, the pathophysiological determinants of TA enlargement in AF patients remain to be clarified. The objectives of this study were (1) to compare the TA size and function in AF patients versus healthy subjects; (2) to identify the determinants of TA remodeling in patients with AF and FTR; and (3) to assess the relationships among right heart structures and severity of FTR in AF patients.

METHODS

Eighty-three consecutive patients with long-term persistent AF and FTR (61 ± 9.9 years, 67% women) were prospectively enrolled and compared with 83 sex and body surface area-matched healthy subjects. Heart chamber size and function and TA geometry were analyzed using three-dimensional echocardiography.

RESULTS

Among AF patients, 33%, 34%, and 33% had mild, moderate, and severe FTR, respectively. Right atrial (RA) dilation was detected in 93% of AF patients, while only 27% and 12% of them showed dilated or dysfunctional right ventricle (RV), respectively. End-diastolic TA area had the strongest correlation with the minimum volume of the RA (RAVmin r = 0.6981, P < .0001) but only mild correlation with RV end-diastolic volume and sex (r = 0.3405, P = .0019; r = 0.2914, P = .0075). At multivariable analysis, only RAVmin was independently associated with TA area in AF patients (r = 0.665, P < .0001). The RAVmin and TA area were the only predictors of FTR severity.

CONCLUSIONS

In patients with AF, RA dilation seems to be more important than RV dilation to determine TA enlargement and subsequent FTR development. The RAVmin and TA area were directly correlated to FTR severity.

Male-female differences in characteristics and early outcomes of patients undergoing tricuspid valve surgery: a national cohort study in the Netherlands

OBJECTIVES

This study aims to explore male-female differences in baseline and procedural characteristics, and outcomes of patients undergoing isolated or concomitant tricuspid valve (TV) surgery.

METHODS

All TV procedures registered between 2007 and 2016 in the database of the Netherlands Association for Cardio-Thoracic Surgery were analysed. Logistic regression analyses with interaction terms were used to determine whether sex was associated with hospital mortality.

RESULTS

Five thousand five hundred and eighty-two patients underwent TV surgery [isolated: N = 685 (49% male), TVrepair: N = 5286 (50% male) and TVreplacement: N = 250 (46% male)]. In the TVrepair group, females were significantly older, had less prior percutaneous/surgical coronary interventions, less extracardiac arteriopathies, a lower prevalence of renal impairment, less endocarditis, a lower prevalence of preoperative critical condition, less recent myocardial infarction, less concomitant coronary artery bypass grafting (CABG) and, in case of concomitant mitral valve surgery, less concomitant mitral valve repair compared to males. In the TVreplacement group, females more often had a history of prior valve surgery and less prior CABG. Hospital mortality for males and females was 7.0% (N = 183) and 6.1% (N = 163), P = 0.241 in the TVrepair group and 2.6% (N = 3) and 8.8% (N = 12), P = 0.074 in the TVreplacement group. Sex was not associated with hospital mortality (odds ratio (OR) 1.14, 95% confidence interval (CI) 0.88-1.48; P = 0.322). Sex demonstrated a significant interaction with the parameter 'critical preoperative condition' (OR 0.44, 95% CI 0.22-0.90; P = 0.026).

CONCLUSIONS

Substantial differences in patient and procedural characteristics existed between male and female patients undergoing TV surgery, although sex was not a derterminant for hospital mortality. Nevertheless, sex interacted with a critical preoperative condition, indicating the usefulness of separate risk factor models for males and females requiring TV surgery.

Catheter ablation or surgical therapy in moderate-severe tricuspid regurgitation caused by long-standing persistent atrial fibrillation. Propensity score analysis

BACKGROUND

This study aimed to describe the mid-term outcomes of different treatments in patients with atrial fibrillation caused tricuspid regurgitation.

METHODS

A retrospective study of patients diagnosed as atrial fibrillation caused moderate-severe tricuspid regurgitation undergoing ablation (n = 411) were reviewed. The surgical cohort (n = 114) underwent surgical ablation and tricuspid valve repair; the catheter cohort (n = 279) was selected from those patients who had catheter ablation.

RESULTS

The estimated actuarial 5-year survival rates were 96.8% (95% CI: 92.95-97.78) and 92.0% (95% CI: 85.26-95.78) in the catheter and surgical cohort, respectively. Tethering height was showed as independent risk factors for recurrent atrial fibrillation and tricuspid regurgitation in both cohorts. A matched group analysis using propensity-matched was conducted after categorizing total patients by tethering height < 6 mm and ≥ 6 mm. Kaplan-Meier analysis showed in patients with tethering height < 6 mm, there were no differences in survival from mortality, stroke, recurrent atrial fibrillation and tricuspid regurgitation between two groups. In patients with tethering height ≥ 6 mm, there were significantly higher cumulative incidence of stroke (95% CI, 0.047-0.849; P = 0.029), recurrent atrial fibrillation (95% CI, 0.357-09738; P = 0.039) and tricuspid regurgitation (95% CI, 0.359-0.981; P = 0.042) in catheter group.

CONCLUSIONS

Atrial fibrillation caused tricuspid regurgitation resulted in less leaflets coaptation, which risk the recurrence of atrial fibrillation and tricuspid regurgitation. Patients whose tethering height was less than 6 mm showed satisfying improvement in tricuspid regurgitation with the restoration of sinus rhythm after catheter ablation. However, in patients with severe leaflets tethering, the results favored surgical over catheter.

The prevalence, predictors, and prognosis of tricuspid regurgitation in stage B and C heart failure with preserved ejection fraction

Aims

Previous studies have demonstrated that moderate/severe tricuspid regurgitation (TR) is associated with adverse outcome in patients with heart failure (HF) with reduced ejection fraction. Little is known about the prevalence and prognostic value of TR in patients of stage B HF and those with stage C HF with preserved ejection fraction (HFpEF). We aimed to investigate the prevalence and prognosis of TR in patients with HFpEF.

Methods and results

From 2013 to 2017, 2014 patients with stage B (n = 1341) or C (n = 673) HFpEF were enrolled in the study. Detailed transthoracic echocardiogram was performed, and the severity of TR was graded as no, mild, moderate, and severe. The mean age of the study population was 66.7 ± 14.1 years old, and 46% were men. Mean left ventricular ejection fraction was 62.2 ± 5.5%. The prevalence of moderate/severe TR increased from stage B to C HF (8% to 16%, respectively, P < 0.01). Older age, hyperlipidaemia, atrial fibrillation, left ventricular mass, and right ventricular systolic pressure were independently associated with moderate/severe TR (P < 0.05 for all). With a median follow‐up of 3.8 (2.9–4.7) years, 346 patients died and 234 developed HF requiring hospitalization. Kaplan–Meier curve revealed that the presence of moderate/severe TR was associated with all‐cause mortality, HF requiring hospitalization and cardiovascular death (log‐rank test P < 0.01). Multivariable analysis demonstrated that moderate (hazard ratio = 1.5; 95% confidence interval: 1.1–2.2; P < 0.05) and severe TR (hazard ratio = 2.1; 95% confidence interval: 1.3–3.3; P < 0.01) were independently associated with mortality, HF requiring hospitalization and cardiovascular death.

Conclusions

The presence of moderate/severe TR is not uncommon in patients with stage B HF and stage C HFpEF. Importantly, moderate/severe TR was independently associated with mortality and HF requiring hospitalization.

Sex-Related Differences in the Mechanism of Functional Tricuspid Regurgitation

BACKGROUND

Predictive factors of significant functional tricuspid regurgitation (FTR) are not completely understood. We investigated sex-related differences in predictors of FTR progression.

METHOD

Clinical and echocardiographic variables were recorded in a prospective single-centre observational cohort of 251 consecutive stable patients with FTR. Multivariable logistic regression analyses stratified by sex were performed to identify predictors of significant FTR.

RESULTS

The mean age of the whole cohort was 72.2±11.4 years, and 133 (53%) patients were women. Females tended to have a higher prevalence of significant FTR (22.6% vs 13.6%; p=0.066). Women were also older than men (mean age 74.4 vs 69.6 years; p<0.001), with more frequent history of arterial hypertension, worse New York Heart Association functional class, higher E/e' quotient, and higher left ventricular ejection fraction. The independent predictors of significant FTR in women were atrial fibrillation (AF) (odds ratio [OR] 10.8, 95% confidence interval [CI] 2.9-40.7; p<0.001), indexed tricuspid diameter annulus (OR 1.24, 95% CI 1.04-1.47; p=0.017), and pulmonary artery systolic pressure (PASP) (OR 1.09, 95% CI 1.04-1.15; p=0.001). The independent predictors of outcome in men were indexed tricuspid tenting height (OR 2.71, 95% CI 1.20-6.11; p=0.016), indexed tricuspid diameter annulus (OR 1.98, 95% CI 1.26-3.09; p=0.003), and PASP (OR 1.08, 95% CI 1.01-1.16; p=0.021).

CONCLUSIONS

The presence of AF and longer indexed tenting height convey a greater risk of significant FTR in females and males, respectively. These findings suggest the existence of different physiopathological mechanisms involved in the progression of FTR in both sexes.

Impact of right ventricular function on development of significant tricuspid regurgitation in patients with chronic atrial fibrillation

BACKGROUND

Chronic atrial fibrillation (AF) can cause significant tricuspid regurgitation (TR), which may result from tricuspid annulus and right atrial enlargement. However, the impact of right ventricular (RV) function on TR development remains unclear.

METHODS

We retrospectively examined 175 consecutive patients with lone chronic AF (duration >1 year) without left ventricular dysfunction. TR severity was graded by the jet area and vena contracta, and moderate or severe TR were defined as significant TR. Patients were classified as significant TR (TR group) or without (NTR group) for comparison of clinical factors and transthoracic echocardiographic (TTE) parameters. To explore factors associated with TR development, we also compared previous TTE parameters among patients in TR group who showed no prior significant TR [TR-preTR(-)] and those in NTR group [NTR-preTR(-)].

RESULTS

The mean age was 78 years (61% men). Significant TR was observed in 61 patients (35%). Compared with NTR group, the TR group was older, and had longer AF duration and larger right-sided cardiac parameters on index TTE. At previous TTE, the TR-preTR(-) group showed a larger basal RV dimension index (26.8 vs. 22.4mm/m²), reduced RV free wall longitudinal strain (RVLS-FW) (-18.96 vs. -23.23), and lower tricuspid annular diameter change during a cardiac cycle (8.8% vs. 14.1%) than NTR-preTR(-) group.

CONCLUSION

Significant TR was observed in 35% of patients with chronic AF. These patients showed enlarged RV, reduced RVLS-FW, and low tricuspid annular diameter changes before significant TR develops. RV dysfunction may be associated with TR development in chronic AF.

Prognostic Importance and Predictors of Survival in Isolated Tricuspid Regurgitation: A Growing Problem

OBJECTIVE

To define mortality associated with isolated tricuspid regurgitation (TR) and identify risk factors associated with decreased survival.

PATIENTS AND METHODS

We conducted a retrospective cohort study of residents of southeastern Minnesota with moderate-severe or more severe isolated TR diagnosed between January 1, 2005, and April 15, 2015. Isolated TR was defined as TR in the absence of left-sided heart disease or pulmonary hypertension. Patients with an ejection fraction of less than 50%, right ventricular systolic pressure greater than 45 mm Hg, moderate or more severe left-sided valve disease, congenital cardiac anomalies, previous valve operation, tricuspid stenosis, flail leaflet, carcinoid, and rheumatic disease were excluded. Five-year survival was compared with age- and sex-matched Minnesota census bureau data. Multivariate regression was used to identify variables associated with mortality.

RESULTS

Over a 10-year period, 289 patients with isolated TR were identified. The mean ± SD age was 79.2±10.6 years, 70.6% (204) were women, atrial fibrillation was present in 74.0% (214), and 24.6% (71) had an intracardiac device. By 5 years after diagnosis, 51.5% had been hospitalized for heart failure. Observed 5-year mortality was 47.8% compared with 36.3% in the census data (P=.005). After adjusting for age and other comorbidities, multivariate regression identified a dilated inferior vena cava (≥2.1 cm) without respiratory variation on echocardiography (hazard ratio, 1.93; 95% CI, 1.13-3.31; P=.02) and creatinine level greater than 1.6 mg/dL (hazard ratio, 1.8; 95% CI, 1.16-2.8; P=.009) as associated with increased mortality.

CONCLUSION

Patients with isolated TR are frequently hospitalized for heart failure and experience excess mortality. Elevated right atrial pressure and renal dysfunction are associated with mortality. This poor outcome may have implications for timing of intervention.