Contemporary insights into the epidemiology, impact and treatment of secondary tricuspid regurgitation across the heart failure spectrum

Abstract

Aim: Tricuspid regurgitation secondary to heart failure (HF) is common with considerable impact on survival and hospitalization rates. Currently, insights into epidemiology, impact, and treatment of secondary tricuspid regurgitation (sTR) across the entire HF spectrum are lacking, yet are necessary for healthcare decision-making.

Methods and results: This population-based study included data from 13 469 patients with HF and sTR from the Viennese community over a 10-year period. The primary outcome was long-term mortality. Overall, HF with preserved ejection fraction was the most frequent (57%, n = 7733) HF subtype and the burden of comorbidities was high. Severe sTR was present in 1514 patients (11%), most common among patients with HF with reduced ejection fraction (20%, n = 496). Mortality of patients with sTR was higher than expected survival of sex- and age-matched community and independent of HF subtype (moderate sTR: hazard ratio [HR] 6.32, 95% confidence interval [CI] 5.88-6.80, p < 0.001; severe sTR: HR 9.04; 95% CI 8.27-9.87, p < 0.001). In comparison to HF and no/mild sTR patients, mortality increased for moderate sTR (HR 1.58, 95% CI 1.48-1.69, p < 0.001) and for severe sTR (HR 2.19, 95% CI 2.01-2.38, p < 0.001). This effect prevailed after multivariate adjustment and was similar across all HF subtypes. In subgroup analysis, severe sTR mortality risk was more pronounced in younger patients (<70 years). Moderate and severe sTR were rarely treated (3%, n = 147), despite availability of state-of-the-art facilities and universal health care.

Conclusion: Secondary tricuspid regurgitation is frequent, increasing with age and associated with excess mortality independent of HF subtype. Nevertheless, sTR is rarely treated surgically or percutaneously. With the projected increase in HF prevalence and population ageing, the data suggest a major burden for healthcare systems that needs to be adequately addressed. Low-risk transcatheter treatment options may provide a suitable alternative.

Keywords: HFmrEF; HFpEF; HFrEF; Heart failure; Secondary tricuspid regurgitation; Transcatheter tricuspid valve intervention.

Figure 1

Contemporary epidemiology of secondary tricuspid regurgitation (TR): overall prevalence of no/mild, moderate and severe secondary TR stratified by age (A) and prevalence of no/mild, moderate, and severe secondary TR for specific heart failure subtypes (B). HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.

Figure 2

Impact of secondary tricuspid regurgitation (sTR): Kaplan–Meier survival analysis according to severity of sTR in patients with heart failure (HF). Long‐term survival analysis comparing patients with HF and no/mild, moderate, or severe sTR (log‐rank p < 0.001) and age‐ and sex‐matched patients for comparison (grey line). CI, confidence interval; HR, hazard ratio.

Figure 3

Subgroup analysis of long‐term mortality for patients with heart failure and severe secondary tricuspid regurgitation. Univariable Cox regression analyses using the median values of the total study population as cutoff points for continuous data. Severe secondary tricuspid regurgitation was a significant predictor in all subgroups, but in patients with severely reduced right ventricular function (RVF). The p for interaction refers to an interaction between severe secondary tricuspid regurgitation and the respective subgroup. CI, confidence interval; LV, left ventricular; RA, right atrial; RV, right ventricular.

Figure 4

Secondary tricuspid regurgitation (sTR) across the heart failure (HF) spectrum. Long‐term survival analysis in patients with sTR (blue: no/mild sTR, yellow: moderate sTR, red: severe sTR) and age‐ and sex‐matched community for expected survival (grey line) in patients with preserved (A, log‐rank p < 0.001), mildly‐reduced (B, log‐rank p <0.001), and reduced ejection fraction (C, log‐rank p <0.001). CI, confidence interval; HR, hazard ratio.