ESC HEART FAILURE
ESC Heart Failure (2024)
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/ehf2.14846

ORIGINAL ARTICLE

Prognostic value of right atrial function in patientswith signiﬁcant tricuspid regurgitation
Takahiro Nishihara , Yoichi Takaya*, Rie Nakayama, Yu Yoshida, Norihisa Toh, Toru Miyoshi,
Kazufumi Nakamura and Shinsuke Yuasa
Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

Abstract
Aims Although right ventricular (RV) dysfunction is associated with adverse outcomes in tricuspid regurgitation (TR), the potential role of right atrial (RA) function is unknown. We aimed to investigate the relationship between RA function and clinicaloutcomes in patients with signiﬁcant TR.
Methods This retrospective study included 169 outpatients with moderate or severe TR due to left-sided heart diseases who
underwent transthoracic echocardiography between June 2020 and April 2023 (average age, 75 ± 10 years; male, 40%). Patients with atrial ﬁbrillation were excluded from this study due to the inaccuracy of the evaluation using 2D
speckle-tracking echocardiography. RA function was compared between patients with and without events, which were deﬁned
as all-cause mortality or hospitalization due to heart failure. RA function was calculated as RA global longitudinal strain(RAGLS) with the 2D speckle-tracking echocardiography.
Results During a median follow-up of 13 months, 19 patients had events (all-cause mortality: 14 cases, hospitalization due toheart failure: 5 cases). RAGLS was lower in patients with events than in those without events (13% ± 10% vs. 18% ± 9%,
P = 0.02). When the patients were categorized into two groups [low RAGLS ≤ 16.2% vs. high RAGLS > 16.2%, high RA volume
index (RAVI) ≥ 50 mL/m2 vs. low RAVI < 50 mL/m2], Kaplan–Meier curves showed that patients with low RAGLS had higher
event rates than those with high RAGLS (log-rank test, P = 0.003). Patients with high RAVI had higher event rates than thosewith low RAVI (log-rank test, P < 0.001). In the multivariate Cox regression analysis, low RAGLS (≤16.2%) was signiﬁcantly associated with events in a model that included RV dysfunction (RV fractional area change ≤ 35%) or high RAVI (≥50 mL/m2)(hazard ratio: 4.55, 95% conﬁdence interval: 1.51–13.71, P < 0.01; hazard ratio: 4.57, 95% conﬁdence interval: 1.52–13.79,
P < 0.01, respectively).
Conclusions RAGLS is associated with all-cause mortality and hospitalization due to heart failure in patients with signiﬁcant
TR. Our results suggest that RA function is a sensitive marker for identifying the risk stratiﬁcation of signiﬁcant TR.
Keywords

echocardiography; prognosis; right atrial function; tricuspid regurgitation

Received: 17 October 2023; Revised: 13 April 2024; Accepted: 24 April 2024
*Correspondence to: Yoichi Takaya, Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-51 Shikata-cho, Kita-ku, Okayama 700-8558, Japan. Email: takayayoichi@okayama-u.ac.jp

Introduction
Tricuspid regurgitation (TR) is a common disease in clinicalpractice. TR usually occurs as a result of annular dilationand leaﬂet tethering caused by right ventricular (RV) remodelling due to volume overload related to left-sided heartdiseases.1,2 Signiﬁcant TR is associated with impaired survival
and worsening heart failure (HF).3–5 Adverse outcomes in TR
have been reported to be affected by RV performance.6,7

The volume overload caused by regurgitation also induces
right atrial (RA) remodelling. RA dilatation and dysfunction
lead to worsening regurgitation, which progresses withright-sided HF. RA performance is often impaired in patientswith TR. The evaluation of RA function may be importantfor determining clinical outcomes in signiﬁcant TR. However,the potential role of RA function is unknown. Recently, 2D
speckle-tracking echocardiography (2D-STE) has been used
to assess RA function. This method non-invasively and auto-© 2024 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,provided the original work is properly cited, the use is non-commercial and no modiﬁcations or adaptations are made.

matically tracks speciﬁed myocardial speckles to evaluate
myocardial motion. Therefore, we hypothesized that the RA
function calculated by the 2D-STE is useful for predicting
adverse outcomes. This study investigated whether RA function is associated with clinical outcomes in patients withsigniﬁcant TR.

T. Nishihara et al.

027). Furthermore, the requirement for informed patientconsent was waived because of the low-risk nature of thestudy and the inability to obtain consent directly from all
patients.

Echocardiographic examination

Methods
Study population and design
This retrospective, single-centre observational study was conducted at Okayama University Hospital, Japan. Figure 1 shows
a ﬂow diagram of the study design. The inclusion criterion
was the presence of moderate or severe TR due toleft-sided heart diseases among patients who underwent
transthoracic echocardiography between June 2020 and April
2023. We excluded the following: (A) a history of adult congenital heart disease, pulmonary arterial hypertension or
pacemaker implantation; (B) atrial ﬁbrillation; and (C) insufﬁcient tracking of RA walls due to poor echocardiographic
image quality. Finally, 169 patients were included in thisstudy. All these patients had clinical symptoms or signs of
HF, according to the 2016 European Society of Cardiology
guidelines.8 Details of clinical characteristics, comorbidities,
drug therapy, laboratory values and echocardiographic ﬁndings were collected from a review of medical records. Among
blood test measurements, haemoglobin, albumin, serum creatinine and plasma B-type natriuretic peptide levels wereobtained.
This study was conducted following the principles of the
Declaration of Helsinki and reviewed and approved by the
ethics committee of the Okayama University Graduate Schoolof Medicine, Dentistry and Pharmaceutical Sciences (2309-

Transthoracic echocardiography was performed using
commercially available equipment (Vivid E95; GE Healthcare,
Milwaukee, WI, USA; and Aplio i900; Canon Medical Systems,
Otawara, Japan). The images were acquired with a breath
hold and recorded for three consecutive heart cycles. Echocardiographic measurements were performed according to
the guidelines.9 Left ventricular (LV) end-diastolic volume,
LV end-systolic volume, LV ejection fraction, LV strokevolume and left atrial (LA) volume index were calculated.
The tissue Doppler-derived early diastolic mitral annular velocity was measured at the septal and lateral wall sites.
The ratio of early diastolic transmitral inﬂow velocity to early
diastolic mitral annular velocity was calculated. The severityof mitral regurgitation or TR was evaluated by a qualitative
assessment using colour Doppler ﬂow imaging. The TR
pressure gradient was measured from the peak velocity. RV
end-diastolic area, RV end-systolic area and RV fractional
area change were measured from an RV-focused apicalfour-chamber view. RV basal diameter was measured in thebasal third of the right ventricle, parallel to the tricuspid annulus at end-diastole.

RA parameters
RA function and volume analyses were performed using
vendor-independent software (TOMTEC Imaging System,
Unterschleissheim, Germany) (Figure 2). All echocardio-

Figure 1 Study ﬂow diagram. RA, right atrial; TR, tricuspid regurgitation.

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3

Figure 2 Representative case of right atrial function measured as right atrial global longitudinal strain (RAGLS) in a patient with tricuspid regurgitation.
(A) A case with a high value of RAGLS (29%). (B) A case with a low value of RAGLS (9%).

graphic images were sent in DICOM format to the corelaboratory. The 2D-STE analyses were performed ofﬂine fromapical four-chamber view images. Three reference points
were placed at the tricuspid annulus and the roof of the rightatrium. The software automatically determined the RA endocardial border and performed speckle-tracking analysis
through one complete cardiac cycle. When an inaccurate RA
endocardial border was detected, manual adjustment was
performed to ensure optimal tracking. The 2D-STE provided
the values of the average RA global longitudinal strain(RAGLS), RA volume, RA fractional area change and RA ejection fraction. RA volume index (RAVI) was calculated by bodysurface area. The 2D-STE analyses were performed by a single
experienced and independent cardiologist who was blinded
to clinical information.

Clinical outcomes
The endpoint was all-cause mortality or hospitalization due
to HF. We reviewed the medical records and conducted
telephone interviews to collect follow-up information.

Statistical analysis
The Shapiro–Wilk test was used to determine the normalityof continuous variables. Continuous variables are represented as mean ± standard deviation or median (interquartile
range) according to the distribution. Categorical variables arepresented as numbers and percentages. Continuous and categorical variables were compared using the paired Student’s
t-test or Mann–Whitney U test and the χ 2 or Fisher’s exact
test, respectively. Cumulative survival estimates were calculated using the Kaplan–Meier method and compared using
the log-rank test. Univariable and multivariable Cox proportional hazard regression analyses were used to clarify variables associated with the occurrence of events. Multivariable
models were constructed, including age, gender, New YorkHeart Association class, LV ejection fraction, RV fractional
area change and RA parameters. The results are reported ashazard ratios (HRs) with 95% conﬁdence intervals (CIs).
Receiver operating characteristic analysis was performed to
identify the optimum cut-off for RAGLS or RAVI to discriminate patients with events using the Youden J statistic. Statistical signiﬁcance was set at P < 0.05. All statistical analyses
were performed using the Statistical Package for the Social

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Prognostic value of right atrial function in patients with signiﬁcant tricuspid regurgitation

T. Nishihara et al.

Sciences software (Version 24; IBM Corp., Armonk, NY, USA)and the R statistical package (Version 4.0.2; R Foundationfor Statistical Computing, Vienna, Austria).

Results

without events, and the symptom of HF was more severe inpatients with events. Patients with events had higher levelsof plasma B-type natriuretic peptide than those without
events. The use of tolvaptan was more frequent in patientswith events than in those without events. After transthoracic
echocardiographic examination, 17 out of 19 (89%) patientswith events had at least taken diuretic drugs.

Patients’ characteristics
The mean age of the patients was 75 ± 10 years, and 40% of
the patients were males. During a median follow-up of
13 months, 19 patients had events (14 cases of all-cause mortality and 5 cases of hospitalization due to HF). Baseline characteristics at the timing of transthoracic echocardiographic
examination are shown in Table 1. The patients’ prevalence
rates of hypertension, dyslipidaemia, diabetes mellitus andchronic kidney disease were 36%, 24%, 16% and 14%, respectively. Patients with events had a signiﬁcantly higher prevalence of chronic kidney disease than those without events.
With respect to HF, patients with events had a signiﬁcantly
higher prevalence of a history of admission for HF than those

Echocardiographic characteristics
Baseline echocardiographic ﬁndings in patients with andwithout events are shown in Table 2. Patients with events
had a lower LV ejection fraction than those without events.
There was no signiﬁcant difference in RV dimension or RV
fractional area change between the two groups. RAGLS was
lower in patients with events than in those without events;
meanwhile, no signiﬁcant difference was observed in RA fractional area change or RA ejection fraction between the twogroups. RAVI was higher in patients with events than in those
without events.

Table 1 Clinical characteristics of the study population.

Age, years
Male gender, n (%)
2
Body surface area (m )Hypertension, n (%)
Dyslipidaemia, n (%)
Diabetes mellitus, n (%)
Chronic kidney disease, n (%)
Current smoker, n (%)
Aetiology of HF, n (%)
Ischaemic heart disease
Non-ischaemic heart disease
HF stage, n (%)
BCDNew York Heart Association class, n (%)
I
II
III
IV
Previous admission for HF, n (%)
Angiotensin-converting enzyme inhibitors
or angiotensin receptor blockers, n (%)
Beta-blocker, n (%)
Loop diuretics, n (%)
Tolvaptan, n (%)
Thiazide, n (%)
Potassium-sparing diuretics, n (%)
Sodium glucose transporter 2 inhibitor, n (%)
Haemoglobin, g/dL
Albumin, g/dL
2
Estimated glomerular ﬁltration rate, mL/min/1.73 m
B-type natriuretic peptide, pg/mL

EventsAll(n = 169)

Present (n = 19)

Absent (n = 150)

P-value

75 ± 1068 (40)1.5 ± 0.2
60 (36)40 (24)26 (16)24 (14)5 (3)75 ± 7
13 (68)1.5 ± 0.1
7 (37)
2 (11)
3 (16)
6 (32)0 (0)75 ± 1155 (37)1.5 ± 0.2
53 (35)38 (25)23 (15)18 (12)
5 (3)

0.76
0.01
0.77
0.90
0.15
0.97
0.02
0.42
0.70

22 (13)147 (87)

3 (16)
16 (84)19 (13)131 (87)

113 (67)
55 (33)1 (1)7 (37)
12 (63)0 (0)106 (70)
43 (29)1 (1)50 (30)93 (55)25 (15)1 (1)31 (18)53 (31)1 (5)8 (42)
10 (53)0 (0)9 (47)
3 (16)

49 (33)85 (57)15 (10)1 (1)22 (15)50 (33)

<0.01
0.12

71 (42)48 (28)
11 (7)6 (4)
38 (23)22 (13)12.0 ± 2.0
3.6 ± 0.756 ± 22476 ± 1231

9 (47)
8 (42)
6 (32)1 (5)
6 (32)
4 (21)
10.6 ± 2.2
3.4 ± 0.5
51 ± 26
1103 ± 1249

62 (41)40 (27)5 (3)5 (3)32 (21)18 (12)
12.2 ± 1.9
3.7 ± 0.7
57 ± 22388 ± 1208

0.62
0.16
<0.01
0.67
0.31
0.27
<0.01
0.12
0.28
0.04

0.01

<0.01

Note: Values are expressed as mean ± standard deviation or number (%).
Abbreviation: HF, heart failure.

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4

Table 2 Baseline echocardiographic characteristics.
EventsLeft chambers
LV end-diastolic volume, mL
LV end-systolic volume, mL
LV stroke volume, mL
LV ejection fraction, %2
LA volume index, mL/m
Early diastolic transmitral inﬂow
velocity/early diastolic mitral annular velocity
Mitral regurgitation
Non/mild/moderate/severe, n (%)
Aortic regurgitation
Non/mild/moderate/severe, n (%)
Right ventricle
RV basal diameter, mm
2
RV end-diastolic area, cm
2
RV end-systolic area, cm
RV fractional area change, %Tricuspid annular plane systolic excursion, mm
Right atrium
2
RAVI, mL/m
RAGLS, %RA fractional area change, %RA ejection fraction, %TRTR moderate/severe, n (%)
TR pressure gradient, mmHg
Inferior vena cava, mm

All (n = 169)

Present (n = 19)

Absent (n = 150)

P-value

90 ± 4137 ± 3154 ± 1864 (60, 66)
48 ± 18
14 (10, 19)

101 ± 50
51 ± 39
50 ± 1556 (47, 65)
54 ± 23
17 (11, 26)

89 ± 4035 ± 2954 ± 1864 (61, 66)
48 ± 18
14 (10, 19)

0.23
0.11
0.4
0.01
0.16
0.19

67/58/37/7 (40/34/22/4)

4/6/8/1 (21/32/42/5)

63/52/29/6 (42/35/19/4)

0.11

112/38/16/3 (66/23/9/2)

12/5/2/0 (63/26/11/0)

100/33/14/3 (67/22/9/2)

0.90

45 ± 617 ± 6
11 ± 438 ± 821 ± 744 ± 519 ± 612 ± 437 ± 620 ± 545 ± 617 ± 6
11 ± 438 ± 821 ± 7

0.71
0.12
0.12
0.61
0.71

57 ± 3118 ± 1023 ± 1128 ± 1475 ± 39
13 ± 1019 ± 1227 ± 1755 ± 29
18 ± 923 ± 1028 ± 14

0.04
0.02
0.16
0.72

155/14 (92/8)
29 (25, 36)
13 ± 6

16/3 (84/16)
36 (25, 43)
16 ± 8139/11 (93/7)
29 (24, 34)
12 ± 5

0.21
0.07
0.01

Note: Values are expressed as mean ± standard deviation, number (%) or median (interquartile range).
Abbreviations: LA, left atrial; LV, left ventricular; RA, right atrial; RAGLS, right atrial global longitudinal strain; RAVI, right atrial volume
index; RV, right ventricular; TR, tricuspid regurgitation.

Association of RA function and volume with
events
The corresponding optimal cut-off values of RAGLS and RAVI
for discriminating the events from the receiver operating
characteristic curve were 16.2% and 50 mL/m2, respectively.
Based on these cut-off values, we categorized thepatients into two groups (low RAGLS ≤ 16.2% vs. high
RAGLS > 16.2%, high RAVI ≥ 50 mL/m2 vs. low
RAVI < 50 mL/m2). Kaplan–Meier curves showed that patients with low RAGLS had higher event rates than those withhigh RAGLS (log-rank test, P = 0.003; Figure 3A). Kaplan–
Meier curves showed that patients with high RAVI had higher
event rates than those with low RAVI (log-rank test,
P < 0.001; Figure 3B). When all the patients were categorizedaccording to the combination of high/low RAGLS and/or
RAVI, Kaplan–Meier curves showed that patients with low
RAGLS and high RAVI had the highest event rates comparedwith the other groups (log-rank test, P < 0.001; Figure 4).
Cox proportional hazard regression analyses were performed to evaluate the determinants of events (Table 3). In
univariate Cox regression analysis, male, New York Heart Association class, LV ejection fraction ≤ 50%, RAVI ≥ 50% and
RAGLS ≤ 16.2% were signiﬁcant determinants of events. In
multivariate Cox regression analysis, RAGLS ≤ 16.2% was as-sociated with events in Model 1 including age and gender(HR, 4.45; 95% CI, 1.46–13.55; P = 0.01), in Model 2 including
New York Heart Association class (HR, 3.27; 95% CI, 1.05–
10.18; P = 0.04), in Model 3 including LV ejection
fraction ≤ 50% (HR, 3.87; 95% CI, 1.27–11.81; P = 0.02), in
Model 4 including RV fractional area change ≤ 35% (HR,4.55; 95% CI, 1.51–13.71; P < 0.01) and in Model 5 including
RAVI ≥ 50% (HR, 4.57; 95% CI, 1.52–13.79; P < 0.01).

Discussion
The present study showed that low RAGLS and high RAVI
were associated with mortality and HF in patients withsigniﬁcant TR. RAGLS remained a predictor after adjustingfor LV function, RV function and RA volume. A cut-off valueof ≤16.2% for RAGLS showed the best accuracy to predict
events. Our results offer additional insights into the evaluation of clinical outcomes in patients with signiﬁcant TR.

TR and RA function
Signiﬁcant TR is observed in 0.55% of the general population,and its prevalence increases with age, affecting approxiESC Heart Failure (2024)
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5Prognostic value of right atrial function in patients with signiﬁcant tricuspid regurgitation

T. Nishihara et al.

Figure 3 Kaplan–Meier curves of cumulative probability of event-free survival. (A) Kaplan–Meier curves according to high or low right atrial global
longitudinal strain (RAGLS). (B) Kaplan–Meier curves according to high or low right atrial volume index (RAVI).

Figure 4 Kaplan–Meier curves of cumulative probability of event-free survival according to the combination of high/low right atrial global longitudinalstrain (RAGLS) and/or right atrial volume index (RAVI).

mately 4% of patients aged 75 years or older.10 More thanmoderate TR has been reported to be associated with a poor
prognosis.3–5 TR is related to remodelling of the right ventricle, which induces RV dilatation and dysfunction. The impairment of RV function progresses with worsening

regurgitation.11 RV dysfunction has been demonstrated to
be a predictor of clinical outcomes in patients with TR.7
TR imposes volume overload on the right atrium as well as
the right ventricle. This volume overload causes not only
atrial dilatation but also impaired atrial stiffness and compliESC Heart Failure (2024)
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63.87 (1.27–11.81) 0.02
3.27 (1.05–10.18) 0.04
4.51 (1.83–11.15) <0.01
4.58 (1.52–13.81) <0.01 4.45 (1.46–13.55) 0.01

0.55
1.32 (0.54–3.25)

5.61 (2.13–14.78) <0.01

Abbreviations: CI, conﬁdence interval; HR, hazard ratio; LV, left ventricular; RAGLS, right atrial global longitudinal strain; RAVI, right atrial volume index; RV, right ventricular.

0.62
1.26 (0.51–3.10)
4.37 (1.64–11.67) 0.01
<0.01
3.31 (1.80–6.11)
0.99
0.01
0.6
1.00 (0.95–1.05)
0.01
3.41 (1.28–9.09)<0.01

Age, years
Male
New York Heart
Association class
LV ejection
fraction≤ 50%
RV fractional areachange ≤ 35%
2
RAVI ≥ 50 mL/m
RAGLS ≤ 16.2%

1.01 (0.97–1.06)
3.52 (1.34–9.27)
4.11 (2.22–7.60)

4.52 (1.82–11.23) <0.01
4.55 (1.51–13.71) <0.01 4.5 (1.52–13.79) <0.01

P-value

Multivariate 5

HR (95% CI)
P-value

Multivariate 4

HR (95% CI)
P-value

Multivariate 3

HR (95% CI)
P-value

Multivariate 2

HR (95% CI)
P-value

Multivariate 1

HR (95% CI)
P-value

Univariate

HR (95% CI)

Table 3 Univariate and multivariate analyses of the prediction of the outcome endpoints.

ance due to inﬂammation, hypertrophy and ﬁbrosis, leading
to atrial dysfunction.12 The right atrium serves as a reservoir
for systemic venous return and has an important role in modulating RV ﬁlling. Thus, RA impairment develops worsening
congestion. RA myocardial ﬁbrosis also affects the electromechanical properties. In addition, the neurohormonal disturbance caused by RA ﬁbrotic stretch manifests as excessively
defective atrial natriuretic peptide synthesis, inducing volume
overload.13 Therefore, the deterioration of RA function may
lead to worse clinical outcomes. Although RA remodelling is
not uncommon in patients with TR, the potential role of RA
function is unknown.

Inﬂuence of RA function on clinical outcomes
There is growing interest in understanding the contribution of
atrial function to cardiac mechanics. The performance of theleft atrium is well known to be associated with clinical outcomes in HF.14,15 LA function has been reported to decline
from the moderate stage of mitral regurgitation and provide
incremental prognostic value.16,17 The prognostic implicationof RA performance has not been fully elucidated, but its clinical importance has recently been highlighted in HF. Ivanov
et al. reported that RA volume measured by cardiac magnetic
resonance imaging was an independent predictor of mortality in patients with HF with preserved ejection fraction.18 Jain
et al. showed that RA function measured by strain analysis on
cardiac magnetic resonance imaging was impaired in patientswith HF and was associated with mortality, independent of LV
or RV function.19 Hasselberg et al. showed that RA function
measured by strain analysis on transthoracic echocardiography, representing the RA reservoir strain, was associated with
5 year mortality in patients with precapillary pulmonary
hypertension.20
The 2D-STE can assess RA function as RAGLS by measuring
the atrial deformation proﬁle during the cardiac cycle. The
evaluation of RA function using the 2D-STE has been shown
to be feasible and reproducible. A systemic review andmeta-analysis of 4111 subjects from 21 studies indicated anormal reference value of 44% (95% CI, 25%–63%) for the
RA reservoir strain,21 which was represented as RAGLS in
the present study.
Regarding the association of RA remodelling with TR,
Muraru et al. reported the role of RA volume as a mechanismof tricuspid annular dilatation and a predictor of TR severity,
irrespective of cardiac rhythm and RV loading conditions.22
Hinojar et al. reported that RA strain indices were related
to TR, with a gradual decline in RA strains with increasing severity of TR.23 They also showed that an RA reservoir strain of<9.4% predicted mortality and HF hospitalization in patientswith TR. However, data on the inﬂuence of RA function arelimited in patients with TR.
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7

Prognostic value of right atrial function in patients with signiﬁcant tricuspid regurgitation

T. Nishihara et al.

Present study

Study limitations

The present study showed that RAGLS had a prognostic value
in patients with signiﬁcant TR. Atrial volume reﬂects thechronic effect of ventricular ﬁlling pressure over time,
whereas atrial function more accurately reﬂects dynamic ventricular ﬁlling pressure. Atrial functional changes occur before
the progression of atrial dilatation. RA function can be usefulfor assessing clinical outcomes in the earlier stages of disease. A previous study reported a cut-off value of <9.4%
for the RA reservoir strain for predicting adverse outcomes,23
whereas our study showed a cut-off value of <16.2% for
RAGLS. This difference between studies appeared to be dueto the difference in study populations. The previous study included patients with severe, massive or torrential TR who had
advanced RA dysfunction,23 unlike our study, which included
patients with moderate or severe TR. Further studies are
required to investigate the adequate cut-off of RAGLS for
identifying clinical outcomes. In addition, RV dysfunction
was not a prognostic factor in the present study. RV dysfunction is a late consequence of changes in the pulmonary
circulation in HF. RA function responds early to changes in
RV compliance.19 RA function can be a sensitive marker forassessing disease severity.
With regard to the treatment of TR, the ﬁrst choice isdrug therapy, mainly diuretics. In the 2021 European Society of Cardiology/European Association for Cardio-Thoracic
Surgery guidelines, tricuspid valve interventions are recommended when RV dilatation or dysfunction occurs.24 However, exact thresholds have not yet been deﬁned becauseclinical evidence on indications for treatments is lacking.
In clinical practice, tricuspid valve interventions may be underused and often initiated too late. Recently, transcatheter
repair has emerged as a less invasive treatment option for
TR. Therefore, the optimal timing of tricuspid valve interventions needs to be considered before irreversible RV
dysfunction and organ damage occur. Our ﬁndings suggestthat the evaluation of RA function is useful for identifying
the risk stratiﬁcation in patients with signiﬁcant TR, which
may help in selecting patients who would beneﬁt fromtreatment.

The present study has certain limitations. First, this study was
conducted retrospectively at a single centre. The number of
events was limited. This could lead to no signiﬁcant difference in the ratio of early diastolic transmitral inﬂow velocity
to early diastolic mitral annular velocity or RV function
between patients with events and those without events.
Long-term follow-up was lacking. Second, because we performed not the quantitative assessment but the qualitative
assessment, we did not evaluate the TR severity in detail.
Third, because we had no data on follow-up transthoracic
echocardiography, we could not assess the inﬂuence of the
medical therapy for HF. Fourth, RA volume and function were
calculated from apical four-chamber view images. The assessment of RA remodelling might be less accurate. Finally, thisstudy excluded patients with atrial ﬁbrillation but included
patients with atrial and functional TR.

Conclusions
RAGLS is an independent predictor of all-cause mortality
and HF hospitalization in patients with signiﬁcant TR. The
assessment of RAGLS could improve risk stratiﬁcation insigniﬁcant TR.

Acknowledgements
All authors appreciate medical technologists for their efforts
in measuring right atrial global longitudinal strain.

Conﬂict of interest statement
None declared.

Funding
None declared.

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Prognostic value of right atrial function in patients with signiﬁcant tricuspid regurgitation