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Observational Study
. 2025 Aug;18(8):e012813.
doi: 10.1161/CIRCHEARTFAILURE.125.012813. Epub 2025 Jul 2.

Determinants of Right Heart Hemodynamic Derangement in Patients With and Without Tricuspid Regurgitation

Sergio Caravita #  1   2 , Michele Liberatore #  2 , Luigi P Badano  2   3 , Maria Felicia Gagliardi  3 , Leila De Lorenzo  4   5 , Antonio Sorropago  6 , Cosmo Godino  5 , Michele Tomaselli  2 , Ettore Lanzarone  1 , Giovanni Battista Perego  2 , Jean-Luc Vachiéry  7 , Marat Fudim  8   9 , Gianfranco Parati  2   3 , Denisa Muraru #  2   3 , Claudia Baratto #  1   2
Affiliations
Observational Study

Determinants of Right Heart Hemodynamic Derangement in Patients With and Without Tricuspid Regurgitation

Sergio Caravita et al. Circ Heart Fail. 2025 Aug.

Abstract

Background: The determinants of tricuspid regurgitation (TR) hemodynamic severity remain to be established. We explored the hemodynamic correlates of right atrial (RA) pressure and stroke volume (SV) in patients with and without TR, and assessed the reliability of the indirect Fick method in relation to TR severity.

Methods: In this observational study, right ventricular (RV) 3-dimensional echocardiography (3DE) was obtained simultaneously with direct Fick right heart catheterization. RVSV3DE and SVRHC were combined to determine the TR regurgitant fraction (RegFr=RVSV3DE-RVSVRHC/RVSV3DE). RA pressures and strain (or 3DE volumes) were combined to derive RA compliance.

Results: Out of 74 patients, 61% had moderate or severe TR. TR severity was associated with larger right heart chambers, lower RA compliance, higher values and lower inspiratory decrease of RA pressure, and lower cardiac index (P<0.01). In univariate analysis, RA V wave was associated with RegFr (r=-0.57) and with ln-transformed RA compliancestrain (r=-0.74); SV index was associated with RegFr (r=-0.65). The effect of RegFr on V wave was mediated by ln-transformed RA compliancestrain (β, 13.9 [95% CI, 7.6-20.2]). In multivariable analysis, RA V wave remained associated with 1/RA compliancestrain (β, 2.1 [95% CI, 1.4-2.7]), while SV index was associated with RegFr (β, -97.6 [95% CI, -120.1 to -75.0]). The indirect Fick method overestimated cardiac index proportionally to RegFr (P<0.01).

Conclusions: SV index is related to TR severity, while the effect of TR on RA V wave is mediated by RA compliance. Respiratory-related changes in RA hemodynamics are associated with TR severity. The indirect Fick method overestimates cardiac index proportionally to TR severity.

Keywords: echocardiography; hemodynamics; humans; stroke volume; tricuspid valve insufficiency.

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Conflict of interest statement

Dr Fudim was supported by the National Institutes of Health, Bodyport, Sardocor, and Doris Duke. He is a consultant/has ownership interest in Abbott, Alleviant, AxonTherapies, and Daxor. Dr Caravita is a consultant to Alleviant. Dr Vachiéry is the holder of the Johnson & Johnson Chair for Pulmonary Hypertension at his institution. The other authors report no conflicts.

Figures

Figure 1.
Figure 1.
Correlation between V wave in the right atrium (RA), tricuspid regurgitation (TR) severity, and right atrial compliance. Tricuspid regurgitation severity is expressed either by regurgitant volume (A) or regurgitant fraction (B). Right atrial compliance is calculated as right atrial volume change (C) or as right atrial reservoir strain (D) over right atrial systolic pressure amplitude.
Figure 2.
Figure 2.
Bland-Altman plots of cardiac index measured by the direct Fick method and estimated by the indirect Fick method. Cardiac index (CI) using the indirect Fick method was obtained with the Dehmer (A), Bergstra (B), and Lafarge and Miettinen (C) equations. The difference between direct and indirect Fick cardiac index is plotted on the y axis, while the reference gold-standard direct Fick cardiac index is plotted on the x axis. Patients with none/mild tricuspid regurgitation (TR) are represented as white dots, those with moderate TR as gray dots, and those with severe TR as black dots. LOA indicates 95% levels of agreement.
Figure 3.
Figure 3.
Combination of right heart catheterization (RHC) and 3-dimensional echocardiography (3DE) to assess the hemodynamic impact of tricuspid regurgitation (TR) volume and right atrial (RA) compliance in patients with TR. CI indicates cardiac index; ECHO, echocardiography; PAWP, pulmonary artery wedge pressure; RAP, right atrial pressure; RAV, right atrial volume; RegVol, regurgitant volume; RV, right ventricle; RVEDV, right ventricular end-diastolic volume; RVESV, right ventricular end-systolic volume; Sao2, arterial oxygen saturation; SV, stroke volume; SvO2, mixed venous oxygen saturation; and VO2, oxygen consumption.
See this image and copyright information in PMC

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